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Income inequality and mental illness-related morbidity and resilience: a systematic review and meta-analysis
Open accessAbstract
Background Studies of the association between income inequality and mental health have shown mixed results, probably due to methodological heterogeneity. By dealing with such heterogeneity through a systematic review and meta-analysis, we examine the association between income inequality, mental health problems, use of mental health services, and resilience (defined as the ability to cope with adversity).Methods We searched the Global Health, PsychARTICLES, PsycINFO, Social Policy and Practice, Embase and MEDLINE databases up to July 6, 2016, for quantitative studies of the association of income inequality with prevalence or incidence of mental disorders or mental health problems, use of mental health services, and resilience. Eligible studies used standardised instruments at the individual level, and income inequality at the aggregated, contextual, and ecological level. We extracted study characteristics, sampling, exposure, outcomes, statistical modelling, and parameters from articles. Because several studies did not provide enough statistical information to be included in a meta-analysis, we did a narrative synthesis to summarise results with studies categorised as showing either a positive association, mixed results, or no association. The primary outcome in the random-effects meta-analysis was mental health-related morbidity, defined as the prevalence or incidence of any mental health problem. This study is registered with PROSPERO, number CRD42016036377.Findings Our search identified 15 615 non-duplicate references, of which 113 were deemed potentially relevant and were assessed for eligibility, leading to the inclusion of 27 studies in the qualitative synthesis. Nine articles found a positive association between income inequality and the prevalence or incidence of mental health problems; ten articles found mixed results, with positive association in some subgroups and non-significant or negative association in other subgroups; and eight articles found no association between income inequality and mental health problems. Of the nine articles included in our meta-analysis, one reported a positive association between income inequality and mental health problems, six reported mixed results, and two reported no association. Pooled Cohen's d effect sizes for the association between income inequality and any mental disorder or mental health problems were 0·06 (95% CI 0·01-0·11) for any mental disorder, and 0·12 (0·05-0·20) for depressive disorders. Our meta-regression analysis showed that none of the factors considered (sample size, contextual level at which income inequality was assessed, quality assessment, type of instruments, and individual income as control variable) explained heterogeneity between studies (I 2 89·3%; p<0·0001). Only one study investigated the association between income inequality and resilience; it found greater income inequality was associated with higher prevalence of depression only among individuals with low income. The only study of the role of income inequality as a determinant of the use of mental health services reported no association.Interpretation Income inequality negatively affects mental health but the effect sizes are small and there is marked heterogeneity among studies. If this association is causal and growing income inequality does lead to an increase in the prevalence of mental health problems, then its reduction could result in a significant improvement in population wellbeing.Funding None.
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“Nonetheless, there is evidence indicating an association between higher income inequality and negative mental health outcomes (Ribeiro et al., 2017).”
From Social media use, economic recession and income inequality in relation to trends in youth suicide in high-income countries: a time trends analysis (2020) · cites this paper as Ribeiro et al., 2017
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“Our study findings bolster the conclusions of recent meta-analyses that have reported a higher risk of depression in populations with greater income inequality [9,10].”
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“…highlighting the correlation between income inequality and the prevalence of mental illness (Patel et al., 2018; Pickett and Wilkinson, 2010; Ribeiro et al., 2017), and individuals from lower socioeconomic backgrounds often report more substantial mental health difficulties…”
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Does inequality have a silver lining? Municipal income inequality and obesity in Mexico
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“We compiled other timevarying location-level variables that might influence the relationship between DALYs and SDI (Barbalat and Franck, 2020; Ribeiro et al., 2017; Wilkinson and Pickett, 2009): income inequalities (defined as the 90/10 ratio: the ratio of the top 10% of incomes to the lowest 10% of incomes and extrac…”
MethodInfluentialThe impact of household wealth gap on individual’s mental health
Zhang, R., Feng, D., Xia, J., & Wang, Y. (2023) · BMC Public Health · doi:10.1186/s12889-023-16871-6 · Cited by 15
No meta-analytical effect of economic inequality on well-being or mental health
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“Supplementary Table 2 presents the a priori-defined, comprehensive 207-term search formula, developed based on previous systematic reviews 42–46 and a preliminary search using PsycInfo.”
The Political Psychology of Inequality
Osborne, D., Becker, J. C., Bahamondes, J., & García‐Sánchez, E. (2022) · Cambridge University Press eBooks · doi:10.1017/9781108779104.026 · Cited by 13
Monzani, L., Bibic, K., Haslam, S. A., Kerschreiter, R., Lemoine, J. E., Steffens, N. K., Akfirat, S. A., Ballada, C. J. A., Bazarov, T. Y., Aruta, J. J. B. R., et al. (2024) · Political Psychology · doi:10.1111/pops.12952 · Cited by 13
“Greater inequality has also been found to predict an increased rate of mental health problems in the general population (e.g., in the form of depression [Ribeiro et al., 2017] and loneliness [Becker et al., 2021]).”
BackgroundGenetic influences on treatment-seeking for common mental health problems in the UK biobank
Rayner, C., Coleman, J. R. I., Purves, K. L., Cheesman, R., Hübel, C., Gaspar, H. A., Glanville, K. P., Krebs, G., Morneau‐Vaillancourt, G., Breen, G. D., et al. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.103413 · Cited by 16
Social status inequality and depression in Europe
Paskov, M., & Richards, L. (2021) · International Journal of Comparative Sociology · doi:10.1177/00207152211022419 · Cited by 11
“A recent review concludes that there is large heterogeneity among studies looking at the relationship between income inequality and mental illness (Ribeiro et al., 2017).”
BackgroundSharpless, L., Kershaw, T., & Willie, T. C. (2022) · SSM - Mental Health · doi:10.1016/j.ssmmh.2022.100085 · Cited by 13
Measuring, Modeling, and Forecasting the Mental Wealth of Nations
Occhipinti, J., Buchanan, J., Skinner, A., Song, Y. J. C., Tran, K., Rosenberg, S. P., Fels, A., Doraiswamy, P. M., Meier, P. S., Prodan, A., et al. (2022) · Frontiers in Public Health · doi:10.3389/fpubh.2022.879183 · Cited by 15
Income, income inequality and schizophrenia in China: a population-based multilevel analysis
Ding, R., Zhang, L., He, P., Song, X., & Zheng, X. (2020) · Journal of Epidemiology & Community Health · doi:10.1136/jech-2019-213049 · Cited by 13
Uncovering the Source of Patrimonial Voting: Evidence from Swedish Twin Pairs
Ahlskog, R., & Brännlund, A. (2021) · Political Behavior · doi:10.1007/s11109-020-09669-4 · Cited by 13
European Forum for Primary Care: Position Paper for Primary Care Mental Health
Smit, D., Hill, L., Walton, I., Kendall, S. A., & Lepeleire, J. D. (2020) · Primary Health Care Research & Development · doi:10.1017/s1463423620000304 · Cited by 15
“We know that certain areas are at higher risk of mental health problems because of greater exposure and vulnerability to unfavorable social, economic, and environmental circumstances (Barnett, 2012; Wilkinson and Pickett, 2017; Ribeiro et al., 2017).”
BackgroundShi, W., Li, T., Zhang, Y., Sun, Q., Chen, C., Fang, J., Du, P., Tang, S., Wang, Q., Wang, J., et al. (2022) · Environmental Research Letters · doi:10.1088/1748-9326/ac5cf6 · Cited by 14
An equity indicator for assessing mental healthcare access: a national population case study
Dawadi, S., Shawyer, F., Callander, E. J., Patten, S. B., Johnson, B. T., Rosenberg, S., Lakra, V., Lin, E. H. B., Teede, H. J., Meadows, G. N., et al. (2024) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796024000738 · Cited by 12
“Countries can implement equivalent indicators, or establish national minimum datasets to track mental health needs and service utilization based on socioeconomic disadvantage and other determinants (Ribeiro et al. , 2017; World Health Organization, 2014).”
Silbersdorff, A., & Schneider, K. S. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16204009 · Cited by 12
Income inequality and student achievement: trends among US States (1992–2019)
Workman, J. B. (2021) · Educational Review · doi:10.1080/00131911.2021.1974349 · Cited by 14
“…found income inequality was associated with: lower selfreported health, lower life expectancy, worse mental health, and higher rates of low birthweight (for literature reviews and meta-analyses see Kondo et al., 2009; Lynch et al., 2004; Ribeiro et al., 2017; Subramanian & Kawachi, 2004).”
BackgroundMunala, L., Welle, E., & Hohenshell, E. (2020) · Journal of Interpersonal Violence · doi:10.1177/0886260520959622 · Cited by 11
“Both household poverty and women’s individual economic inequality and dependence are associated with higher rates of interpersonal violence, including sexual violence (Bamiwuye & Odimegwu 2014; Breiding et al., 2017; Kishor & Johnson, 2005; Ribeiro et al., 2017).”
BackgroundScatolon, A., & Paladino, M. P. (2022) · British Journal of Social Psychology · doi:10.1111/bjso.12620 · Cited by 11
Sigurdardottir, S., Aspelund, T., Guðmundsdóttir, D. G., Fjorback, L. O., Hrafnkelsson, H., Hansdóttir, I., & Juul, L. (2023) · BMC Psychiatry · doi:10.1186/s12888-022-04504-y · Cited by 11
Said, M. A., Thangiah, G., Majid, H. A., İsmail, R., Tan, M. P., Rizal, H., Zaidi, M. A. S., Reidpath, D. D., & Su, T. T. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19116604 · Cited by 12
“Widening income inequality in communities erodes social capital and trustworthiness within societies through status comparison [20,21], thus creating loneliness and isolation [7].”
BackgroundPatterns of brain-wide associations reflect socioeconomics
Marek, S. A., Donohue, M. R., Karcher, N. R., Hoyniak, C. P., Chauvin, R. J., Meyer, A. C., Miller, J. M., Van, A. N., Wang, A., Baden, N. J., et al. (2026) · Science · doi:10.1126/science.aee6213 · Cited by 20
Rossi, R., Lorenzo, G. D., Jannini, T. B., Ossola, P., Murri, M. B., Siracusano, A., & Rossi, A. (2024) · International Journal of Social Psychiatry · doi:10.1177/00207640241242017 · Cited by 10
Understanding Mental Disorders, Mental Health and Well-Being
Murthy, R. S. (2024) · Springer eBooks · doi:10.1007/978-981-97-1203-8_2 · Cited by 11
Hyldelund, N. B., Byrne, D. V., Chan, R. C. K., & Andersen, B. V. (2022) · Foods · doi:10.3390/foods11223659 · Cited by 11
Tibbetts, J., Chapman, C., O’Dean, S., Butterworth, P., & Slade, T. N. (2025) · SSM - Mental Health · doi:10.1016/j.ssmmh.2025.100481 · Cited by 11
Haugan, T., Muggleton, S., & Myhr, A. (2021) · PLoS ONE · doi:10.1371/journal.pone.0254033 · Cited by 9
“In line with other population-based studies [50,110,111], our findings linked income inequality with poor mental health outcomes.”
ResultKarimi, M., Thani, F. N., Naqhsh, Z., & Ghazaghi, T. (2022) · Iranian Journal of Psychiatry and Behavioral Sciences · doi:10.5812/ijpbs.107467 · Cited by 9
Metadata
- Authors
- Ribeiro, W. S., Bauer, A., Andrade, M. C. R., York-Smith, M., Pan, P. M., Pingani, L., Knapp, M., Coutinho, E. S. F., & Evans-Lacko, S.
- Affiliations
- London School of Economics and Political Science (GB)
- Universidade Federal de São Paulo (BR)
- University of Modena and Reggio Emilia (IT)
- Escola Nacional de Saúde Pública Sergio Arouca (BR)
- Corresponding author
- Ribeiro, Wagner Silva
- ORCID
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2017-07
- Volume
- 4
- Issue
- 7
- Pages
- 554-562
- ISSN
- 2215-0366 (ISSN-L)
- OpenAlex
- W2618040738
- Cited by
- 240
- References
- 52
- Citations by year
- 2026: 19 · 2025: 36 · 2024: 40 · 2023: 31 · 2022: 37 · 2021: 34 · 2020: 19 · 2019: 11 · 2018: 9 · 2017: 3
- FWCI
- 1.99
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- London School of Economics and Political Science Research Online (London School of Economics and Political Science) (acceptedVersion)
- IRIS UNIMORE (University of Modena and Reggio Emilia) (submittedVersion, cc-by)
- London School of Economics and Political Science Research Online (London School of Economics and Political Science) (submittedVersion)
- UNIFESP Institutional Repository (Universidade Federal de São Paulo) (submittedVersion)
- Funders
- European Research Council under the European Union's Seventh Framework Programme (FP7/2007-2013)
- Topics
- Social Sciences › Health › Health disparities and outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Employment and Welfare Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Keywords
- income inequality, mental health, resilience, mental health service utilization, depressive disorders, socioeconomic status, personal income, methodological heterogeneity, coping with adversity, mental health promotion and prevention
- MeSH terms
- Adolescent, Adult, Aged, Mental Disorders, Child, Depression, Female, Humans, Income, Male, Mental Health, Middle Aged, Morbidity, Public Policy, Socioeconomic Factors, Incidence, Prevalence, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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