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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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“Income inequality can affect human capital investment (Kearney & Levine, 2016), health (Pickett & Wilkinson, 2015), mental health (Ribeiro et al., 2017), and crime (Kelly, 2000).”
Alabdulkarem, K. B., Alshammari, G. M., Alyousef, A. A., MOHAMMED, M. A., Fattiny, S. Z. A., Alqahtani, I. Z., & Yahya, M. A. (2024) · Healthcare · doi:10.3390/healthcare12232419 · Cited by 2
Almeida, M. L., Mallmann, M. Y., Vescovi, G., Riter, H. D. S., Bandeira, P. F. R., Fitzpatrick, C., Bandeira, D. R., & Frizzo, G. B. (2025) · International Journal of Systemic Therapy · doi:10.1080/2692398x.2025.2450550 · Cited by 1
“Those variables have well-established associations with child development and maternal mental health (Letourneau et al., 2013; Ribeiro et al., 2017), but studies are still inconclusive regarding their relations with screen exposure.”
Carlsson, E., Hemmingsson, T., Landberg, J., Burström, B., & Thern, E. (2025) · European Journal of Public Health · doi:10.1093/eurpub/ckae212 · Cited by 1
Banks and Long-Run Economic Prosperity
Levine, R. E. (2025) · Oxford University Press eBooks · doi:10.1093/oxfordhb/9780198897071.013.4 · Cited by 1
Neville, T. H., Walling, A. M., Wenger, N. S., Mittman, B. S., Tseng, C., Chang, D., Cook, D., Ruiz, C. J. M., CASSANO, H., Beers, E., et al. (2025) · PLoS ONE · doi:10.1371/journal.pone.0320843 · Cited by 1
“Families of patients who die in intensive care units (ICUs) often suffer from anxiety and depression [13–16], post-traumatic stress disorder (PTSD) [14–16], and complicated grief [17], all of which can be exacerbated by social inequality [18–20].”
Goldstein, E. V. (2021) · Psychiatric Services · doi:10.1176/appi.ps.202100478 · Cited by 1
Banerjee, D., & Bhattacharya, P. (2022) · Oxford University Press eBooks · doi:10.1093/med/9780198861478.003.0021 · Cited by 1
Funding of mental health services
Chisholm, D., Knapp, M. R. J., & Jadoolal, S. (2011) · doi:10.1093/med/9780198898818.003.0033 · Cited by 1
Enhancing mental health practice in Sierra Leone : a social intervention development study
Fendt-Newlin, M. (2018) · White Rose eTheses Online (University of Leeds, The University of Sheffield, University of York) · Cited by 1
Schafers, C. L., & Wormith, J. S. (2022) · Elsevier eBooks · doi:10.1016/b978-0-323-91497-0.00161-2 · Cited by 2
Oberwittler, D. (2023) · Springer eBooks · doi:10.1007/978-3-662-64465-2_2 · Cited by 1
Jamieson, S. R., Swickard, S. M., Cahill, A. L., Powell, S. S., Samuels, K., & Hartos, J. L. (2018) · Frontiers in Women’s Health · doi:10.15761/fwh.1000148
“Furthermore, our research found no consistent relationship between mental health and income, which is similar to the results of a previous review study [8] that showed that only 1 of 9 studies showed consistent associations between income inequality and poor mental health, while the others showed mixed results or no a…”
BackgroundResultMentale und physische Gesundheit im Alter
Franzese, F. (2020) · Budrich Academic Press eBooks · doi:10.3224/96665012 · Cited by 4
Wu, N., & Gao, B. (2020) · doi:10.21203/rs.3.rs-22176/v1
Discussion of Findings on Social Determinants of Health
Xafis, V., Fakhouri, A., Currow, K., Brancatisano, S., & Bryan-Clothier, W. (2021) · Springer eBooks · doi:10.1007/978-981-16-3338-6_5
Sherwood, J. (2021) · PDXScholar (Portland State University) · doi:10.15760/etd.7636 · Cited by 1
Du, H., Huang, Y., Ma, L., Chen, X., Chi, P., & King, R. B. (2021) · doi:10.31219/osf.io/tr9jn
Contemporary Challenges to Democracy
(2022) · Cambridge University Press eBooks · doi:10.1017/9781108779104.025
Xafis, V., Fakhouri, A., Currow, K., Brancatisano, S., & Bryan-Clothier, W. (2021) · Springer eBooks · doi:10.1007/978-981-16-3338-6_1
Campion, J. (2022) · Oxford University Press eBooks · doi:10.1093/med/9780198861478.003.0051
Kaur, M., & Singla, N. (2022) · Indian Journal of Dairy Science · doi:10.33785/ijds.2022.v75i04.012
Depression, Anxiety, and Insomnia of Chinese Quarantine People During the COVID-19 Pandemic
(2022) · Advances in Bioengineering and Biomedical Science Research · doi:10.33140/abbsr.05.04.03
Evans-Lacko, S. E. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr6
Evans-Lacko, S. E., Araya, R., Bauer, A., et al. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr9
Evans-Lacko, S. E., Araya, R., Bauer, A., et al. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr10
Evans-Lacko, S. E., Araya, R., Bauer, A., et al. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr8
Evans-Lacko, S. E., Araya, R., Bauer, A., et al. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr7
Evans-Lacko, S. E., Araya, R., Bauer, A., et al. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr5
Evans-Lacko, S. E., Araya, R., Bauer, A., et al. (2023) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr4
Evans-Lacko, S. E., Araya, R., Bauer, A., et al. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr3
Evans-Lacko, S. E. (2022) · Cambridge Prisms Global Mental Health · doi:10.1017/gmh.2023.4.pr1
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
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