- Email: [email protected]
Inequality and mental illness
Comment
Finnish National data should be replicated; more randomised trials of lithium monotherapy in unipolar depression should be conducted and, if the benefits are verified, practice should reflect this. Finally, all aspects of lithium and its effects on the brain and behaviour should be the focus of continuing rigorous scientific enquiry. Allan H Young Centre for Affective Disorders, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AZ, UK [email protected] AY is employed by King’s College London as an Honorary Consultant SLaM (NHS UK), and has been paid for lectures and advisory boards for the following companies with drugs used in affective and related disorders: AstraZeneca, Eli Lilly, Janssen, Lundeck, Sunovion, Servier, Livanova. This report represents independent research funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the author and not necessarily those of the NHS, the NIHR, or the Department of Health. 1
Blackwell B, Shepherd M. Prophylactic lithium: another therapeutic myth? An examination of the evidence to date. Lancet 1968; 1: 968–71.
2
Hayes JF, Marston L, Walters K, Geddes JR, King M, Osborn DP. Adverse renal, endocrine, hepatic, and metabolic events during maintenance mood stabilizer treatment for bipolar disorder: a population-based cohort study. PLoS Med 2016; 13: e1002058. 3 Young AH. Lithium and suicide. Lancet Psychiatry 2014; 1: 483–84. 4 Young AH. More good news about the magic ion: lithium may prevent dementia. Br J Psychiatry 2011; 198: 336–37. 5 Huang RY, Hsieh KP, Huang WW, Yang YH. Use of lithium and cancer risk in patients with bipolar disorder: population-based cohort study. Br J Psychiatry 2016; 209: 393–99. 6 Souza FG, Goodwin GM. Lithium treatment and prophylaxis in unipolar depression: a meta-analysis. Br J Psychiatry 1991; 158: 666–75. 7 Bauer M, Severus E, Möller HJ, Young AH, WFSBP Task Force on Unipolar Depressive Disorders. Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. Int J Psychiatry Clin Pract 2017; 3: 1–11. 8 Tiihonen J, Tanskanen A, Hoti F, et al. Pharmacological treatments and risk of readmission to hospital for unipolar depression in Finland: a nationwide cohort study. Lancet Psychiatry 2017; published online June 1. http://dx.doi.org/10.1016/S2215-0366(17)30134-7. 9 Cipriani A, Smith K, Burgess S, Carney S, Goodwin G, Geddes J. Lithium versus antidepressants in the longterm treatment of unipolar affective disorder. Cochrane Database Syst Rev 2006; 4: CD003492. 10 Gøtzsche PC, Young AH, Crace J. Does long term use of psychiatric drugs cause more harm than good? BMJ 2015; 350: h2435. 11 Helbich M, Leitner M, Kapusta ND. Lithium in drinking water and suicide mortality: interplay with lithium prescriptions. Br J Psychiatry 2015; 207: 64–71.
Jim West/Science Photo Library
Inequality and mental illness
Published Online May 25, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30206-7 See Articles page 554
512
For at least 40 years, research evidence has been accumulating that societies with larger income differences between rich and poor tend to have worse health and higher homicide rates. More recently, this has been contextualised by findings that more unequal societies not only have higher rates of poor health and violence, but also of other outcomes that tend to be worse lower down the social ladder, including teenage births, lower maths and literacy scores, obesity, and imprisonment.1 Taken together, the hundreds of research papers on these effects of inequality suggest that the relationships meet the epidemiological criteria for causality.2 Although there might be some reverse causality through which poor health increases inequality,2 much more important are the ways in which inequality causes ill health and social dysfunction. The causal pathways seem to be mediated by the effects of inequality on social capital and trust, and are largely independent of absolute material living standards and of the benefits of public services.3,4 Mental illness is the most recent addition to this list of effects of greater inequality. In a meta-analysis of research on the relation between income inequality and mental illness in The Lancet Psychiatry, Wagner
Ribeiro and colleagues5 report that greater inequality is associated with higher rates of mental illness, especially depression and anxiety disorders. This study is especially interesting in view of an earlier review by Johnson and colleagues6 that, on the basis of a very large body of evidence, showed that the human brain’s dominance behavioural system—which processes issues associated with social dominance and subordination—is likely to be involved in a broad range of mental illnesses and personality disorders. Specifically, the researchers suggested that externalising disorders, mania proneness, and narcissistic traits are related to heightened dominance motivation, while anxiety and depression are related to subordination (or the attempt to avoid it) and to submissiveness. More frequent occurrence of mental disorders that involve the dominance behavioural system in societies with bigger income differences between rich and poor would be consistent with the suggestion that greater inequalities increase the salience of issues to do with dominance and subordination. The evidence that many health and social problems with inverse social gradients are also more common in more unequal societies7 carries the same implication. www.thelancet.com/psychiatry Vol 4 July 2017
Comment
Ribeiro and colleagues’ meta-analytic review of the relation between mental illness and income inequality5 finds modest effect sizes—pooled Cohen’s d effect size 0·06 (95% CI 0·01–0·11) for any mental health problem and 0·12 (0·05–0·197) for depressive disorders—but two points need to be kept in mind. First, exposure to inequality affects the whole population, so even a small effect size means that the additional number of people with mental illness attributable to inequality is very large. Second, these effect sizes come from multilevel models that exclude the direct effects of individual high or low income. Insofar as some of the effect of individual income is to create the feelings of superiority and inferiority in relation to others through which inequality is likely to have its effect, this leads to a substantial underestimate of the effects of inequality. The quality of social relations has a powerful effect on mental health. There is a growing body of research that suggests that greater inequality is a social stressor irrespective of average living standards.8 A study in 31 European countries found that status anxiety was higher at all income levels in more unequal societies, again suggesting that increased inequality heightens the importance of status differences.9 An illustration of the powerful psychosocial effects of relative poverty comes from a study in which people experiencing poverty were interviewed in seven countries at different levels of development.10 Researchers noted that although material circumstances of the poor in countries as rich as Norway or Britain appear luxurious in comparison with poverty in India or Pakistan, the experience of poverty was remarkably similar. Being poor in relation to others meant people in each society were unable to escape feeling despised, shamed, and humiliated. Whether people live in a shack with an earth floor and no sanitation, or in a three bedroom house with
fridge, washing machine, and television, low social status is experienced as overwhelmingly degrading. As inequality makes social status more important, this also explains why violence, triggered by loss of face, humiliation, and disrespect, is more common in more unequal societies.11 As the American anthropologist Marshal Sahlins pointed out, poverty is above all, “a relation between people...an invidious distinction between classes”.12 It is also a warning against the common assumption, made by Ribeiro and colleagues as well, that associations with poverty, even in developed countries, necessarily reflect the effects of material rather than psychosocial processes. We all need to feel valued. *Richard Wilkinson, Kate Pickett Department of Health Sciences, University of York, York, UK [email protected] Both authors are trustees of The Equality Trust, a registered charity. We declare no competing interests. 1
Wilkinson RG, Pickett K. The Spirit Level: Why Equality is Better for Everyone. London: Penguin; 2010. 2 Pickett KE, Wilkinson RG. Income inequality and health: a causal review. Social Science & Medicine 2015; 128: 316–26. 3 Elgar FJ. Income inequality, trust, and population health in 33 countries. Am J Public Health 2010; 100: 2311–15. 4 Layte R. The association between income inequality and mental health: testing status anxiety, social capital, and neo-materialist explanations. Eur Sociol Rev 2012; 28: 498–511. 5 Ribeiro WS, Bauer A, Andrade MCR, et al. Income inequality and mental illness-related morbidity and resilience: a systematic review and meta-analysis. Lancet Psychiatry 2017; published online May 25. http://dx.doi.org/10.1016/S2215-0366(17)30159-1. 6 Johnson SL, Leedom LJ, Muhtadie L. The dominance behavioral system and psychopathology: evidence from self-report, observational, and biological studies. Psych Bull 2012; 138: 692–743. 7 Wilkinson RG, Pickett KE. Income inequality and socioeconomic gradients in mortality. Am J Public Health 2008; 98: 699–704. 8 Wilkinson RG, Pickett KE. The enemy between us: The psychological and social costs of inequality. Eur J Soc Psychol 2017; 47: 11–41. 9 Layte R, Whelan CT. Who feels inferior? A test of the status anxiety hypothesis of social inequalities in health. Eur Sociol Rev 2014; 30: 525–35. 10 Walker R, Kyomuhendo GB, Chase E, et al. Poverty in global perspective: is shame a common denominator? J Soc Policy 2013; 42: 215–33. 11 Gilligan J. Preventing Violence. New York: Thames and Hudson, 2001. 12 Sahlins M. Stone Age Economics. London: Routledge, 2003.
Medical marijuana research for chronic pain Cannabinoids have been used for millennia to alleviate suffering. According to the sacred Hindu texts the Vedas, cannabis is a divine plant. Notwithstanding its long history in healing, cultural, and recreational contexts, few medical treatments are as polarising as medical marijuana (MMJ).1 Opinions reside along a spectrum ranging from a panacea that can alleviate www.thelancet.com/psychiatry Vol 4 July 2017
all suffering to a hardcore drug with little clinical utility that is being medicalised in a veiled attempt to legitimise recreational use.1 Similar to other hotbutton topics, viewpoints are influenced by cultural prejudices. Chronic pain and psychiatric morbidity considerably overlap, including depression, substance abuse, anxiety 513
Finnish National data should be replicated; more randomised trials of lithium monotherapy in unipolar depression should be conducted and, if the benefits are verified, practice should reflect this. Finally, all aspects of lithium and its effects on the brain and behaviour should be the focus of continuing rigorous scientific enquiry. Allan H Young Centre for Affective Disorders, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AZ, UK [email protected] AY is employed by King’s College London as an Honorary Consultant SLaM (NHS UK), and has been paid for lectures and advisory boards for the following companies with drugs used in affective and related disorders: AstraZeneca, Eli Lilly, Janssen, Lundeck, Sunovion, Servier, Livanova. This report represents independent research funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the author and not necessarily those of the NHS, the NIHR, or the Department of Health. 1
Blackwell B, Shepherd M. Prophylactic lithium: another therapeutic myth? An examination of the evidence to date. Lancet 1968; 1: 968–71.
2
Hayes JF, Marston L, Walters K, Geddes JR, King M, Osborn DP. Adverse renal, endocrine, hepatic, and metabolic events during maintenance mood stabilizer treatment for bipolar disorder: a population-based cohort study. PLoS Med 2016; 13: e1002058. 3 Young AH. Lithium and suicide. Lancet Psychiatry 2014; 1: 483–84. 4 Young AH. More good news about the magic ion: lithium may prevent dementia. Br J Psychiatry 2011; 198: 336–37. 5 Huang RY, Hsieh KP, Huang WW, Yang YH. Use of lithium and cancer risk in patients with bipolar disorder: population-based cohort study. Br J Psychiatry 2016; 209: 393–99. 6 Souza FG, Goodwin GM. Lithium treatment and prophylaxis in unipolar depression: a meta-analysis. Br J Psychiatry 1991; 158: 666–75. 7 Bauer M, Severus E, Möller HJ, Young AH, WFSBP Task Force on Unipolar Depressive Disorders. Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. Int J Psychiatry Clin Pract 2017; 3: 1–11. 8 Tiihonen J, Tanskanen A, Hoti F, et al. Pharmacological treatments and risk of readmission to hospital for unipolar depression in Finland: a nationwide cohort study. Lancet Psychiatry 2017; published online June 1. http://dx.doi.org/10.1016/S2215-0366(17)30134-7. 9 Cipriani A, Smith K, Burgess S, Carney S, Goodwin G, Geddes J. Lithium versus antidepressants in the longterm treatment of unipolar affective disorder. Cochrane Database Syst Rev 2006; 4: CD003492. 10 Gøtzsche PC, Young AH, Crace J. Does long term use of psychiatric drugs cause more harm than good? BMJ 2015; 350: h2435. 11 Helbich M, Leitner M, Kapusta ND. Lithium in drinking water and suicide mortality: interplay with lithium prescriptions. Br J Psychiatry 2015; 207: 64–71.
Jim West/Science Photo Library
Inequality and mental illness
Published Online May 25, 2017 http://dx.doi.org/10.1016/ S2215-0366(17)30206-7 See Articles page 554
512
For at least 40 years, research evidence has been accumulating that societies with larger income differences between rich and poor tend to have worse health and higher homicide rates. More recently, this has been contextualised by findings that more unequal societies not only have higher rates of poor health and violence, but also of other outcomes that tend to be worse lower down the social ladder, including teenage births, lower maths and literacy scores, obesity, and imprisonment.1 Taken together, the hundreds of research papers on these effects of inequality suggest that the relationships meet the epidemiological criteria for causality.2 Although there might be some reverse causality through which poor health increases inequality,2 much more important are the ways in which inequality causes ill health and social dysfunction. The causal pathways seem to be mediated by the effects of inequality on social capital and trust, and are largely independent of absolute material living standards and of the benefits of public services.3,4 Mental illness is the most recent addition to this list of effects of greater inequality. In a meta-analysis of research on the relation between income inequality and mental illness in The Lancet Psychiatry, Wagner
Ribeiro and colleagues5 report that greater inequality is associated with higher rates of mental illness, especially depression and anxiety disorders. This study is especially interesting in view of an earlier review by Johnson and colleagues6 that, on the basis of a very large body of evidence, showed that the human brain’s dominance behavioural system—which processes issues associated with social dominance and subordination—is likely to be involved in a broad range of mental illnesses and personality disorders. Specifically, the researchers suggested that externalising disorders, mania proneness, and narcissistic traits are related to heightened dominance motivation, while anxiety and depression are related to subordination (or the attempt to avoid it) and to submissiveness. More frequent occurrence of mental disorders that involve the dominance behavioural system in societies with bigger income differences between rich and poor would be consistent with the suggestion that greater inequalities increase the salience of issues to do with dominance and subordination. The evidence that many health and social problems with inverse social gradients are also more common in more unequal societies7 carries the same implication. www.thelancet.com/psychiatry Vol 4 July 2017
Comment
Ribeiro and colleagues’ meta-analytic review of the relation between mental illness and income inequality5 finds modest effect sizes—pooled Cohen’s d effect size 0·06 (95% CI 0·01–0·11) for any mental health problem and 0·12 (0·05–0·197) for depressive disorders—but two points need to be kept in mind. First, exposure to inequality affects the whole population, so even a small effect size means that the additional number of people with mental illness attributable to inequality is very large. Second, these effect sizes come from multilevel models that exclude the direct effects of individual high or low income. Insofar as some of the effect of individual income is to create the feelings of superiority and inferiority in relation to others through which inequality is likely to have its effect, this leads to a substantial underestimate of the effects of inequality. The quality of social relations has a powerful effect on mental health. There is a growing body of research that suggests that greater inequality is a social stressor irrespective of average living standards.8 A study in 31 European countries found that status anxiety was higher at all income levels in more unequal societies, again suggesting that increased inequality heightens the importance of status differences.9 An illustration of the powerful psychosocial effects of relative poverty comes from a study in which people experiencing poverty were interviewed in seven countries at different levels of development.10 Researchers noted that although material circumstances of the poor in countries as rich as Norway or Britain appear luxurious in comparison with poverty in India or Pakistan, the experience of poverty was remarkably similar. Being poor in relation to others meant people in each society were unable to escape feeling despised, shamed, and humiliated. Whether people live in a shack with an earth floor and no sanitation, or in a three bedroom house with
fridge, washing machine, and television, low social status is experienced as overwhelmingly degrading. As inequality makes social status more important, this also explains why violence, triggered by loss of face, humiliation, and disrespect, is more common in more unequal societies.11 As the American anthropologist Marshal Sahlins pointed out, poverty is above all, “a relation between people...an invidious distinction between classes”.12 It is also a warning against the common assumption, made by Ribeiro and colleagues as well, that associations with poverty, even in developed countries, necessarily reflect the effects of material rather than psychosocial processes. We all need to feel valued. *Richard Wilkinson, Kate Pickett Department of Health Sciences, University of York, York, UK [email protected] Both authors are trustees of The Equality Trust, a registered charity. We declare no competing interests. 1
Wilkinson RG, Pickett K. The Spirit Level: Why Equality is Better for Everyone. London: Penguin; 2010. 2 Pickett KE, Wilkinson RG. Income inequality and health: a causal review. Social Science & Medicine 2015; 128: 316–26. 3 Elgar FJ. Income inequality, trust, and population health in 33 countries. Am J Public Health 2010; 100: 2311–15. 4 Layte R. The association between income inequality and mental health: testing status anxiety, social capital, and neo-materialist explanations. Eur Sociol Rev 2012; 28: 498–511. 5 Ribeiro WS, Bauer A, Andrade MCR, et al. Income inequality and mental illness-related morbidity and resilience: a systematic review and meta-analysis. Lancet Psychiatry 2017; published online May 25. http://dx.doi.org/10.1016/S2215-0366(17)30159-1. 6 Johnson SL, Leedom LJ, Muhtadie L. The dominance behavioral system and psychopathology: evidence from self-report, observational, and biological studies. Psych Bull 2012; 138: 692–743. 7 Wilkinson RG, Pickett KE. Income inequality and socioeconomic gradients in mortality. Am J Public Health 2008; 98: 699–704. 8 Wilkinson RG, Pickett KE. The enemy between us: The psychological and social costs of inequality. Eur J Soc Psychol 2017; 47: 11–41. 9 Layte R, Whelan CT. Who feels inferior? A test of the status anxiety hypothesis of social inequalities in health. Eur Sociol Rev 2014; 30: 525–35. 10 Walker R, Kyomuhendo GB, Chase E, et al. Poverty in global perspective: is shame a common denominator? J Soc Policy 2013; 42: 215–33. 11 Gilligan J. Preventing Violence. New York: Thames and Hudson, 2001. 12 Sahlins M. Stone Age Economics. London: Routledge, 2003.
Medical marijuana research for chronic pain Cannabinoids have been used for millennia to alleviate suffering. According to the sacred Hindu texts the Vedas, cannabis is a divine plant. Notwithstanding its long history in healing, cultural, and recreational contexts, few medical treatments are as polarising as medical marijuana (MMJ).1 Opinions reside along a spectrum ranging from a panacea that can alleviate www.thelancet.com/psychiatry Vol 4 July 2017
all suffering to a hardcore drug with little clinical utility that is being medicalised in a veiled attempt to legitimise recreational use.1 Similar to other hotbutton topics, viewpoints are influenced by cultural prejudices. Chronic pain and psychiatric morbidity considerably overlap, including depression, substance abuse, anxiety 513