Educational inequalities in major depressive disorder over the adult life course: a microsimulation

Abstract Background Educational inequalities in major depressive disorder (MDD) pose a major challenge. Tackling this issue requires evidence on the long-term impact of intervening on modifiable factors, e.g. behavioural and psychosocial factors. Therefore, we aim to simulate the development of educational inequalities in MDD across the life course, and to assess the impact of intervening on the modifiable factors that contribute to these inequalities. Methods We used data from the prospective Dutch Lifelines Cohort Study to estimate the required input for a continuous-time microsimulation. The microsimulation allowed us to estimate the development of educational inequalities in MDD with a synthetic cohort of 500,000 individuals followed from ages 18 to 65, and to assess the potential benefit of intervening on quality of social contacts, health literacy, and smoking. Results On average, an additional 19.1% of individuals with low education will ever experience MDD between ages 18 and 65 compared to those with high education (32.0% vs 12.9%, respectively). Additionally, individuals with low education generally will develop MDD 0.9 years earlier (35.6 years vs 36.5 years, respectively) and spend 1.2 years more with MDD (6.2 years vs 5 years, respectively), than individuals with high education. Improving the quality of social contacts in individuals with low education would have the largest impact; it would reduce the inequalities in the prevalence, onset, and duration of MDD by an average of 18.4%, 18.3%, and 28.6%, respectively. Conclusions Intervening on modifiable factors, especially quality of social contacts, in individuals with low education could help reduce the large estimated educational inequalities in MDD over the life course. Key messages • There are large educational inequalities in major depressive disorder (MDD) over the life course, especially with regard to the life course prevalence of MDD. • Improving quality of social contacts, and to a lesser extent health literacy and smoking behaviours, amongst individuals with low education may help reduce the inequalities in MDD.


Introduction:
Population health, including mental health, is influenced by its socioeconomic context. After the 2008 global economic crisis, studies found contradicting results: some showed an increased risk for self-harm and suicidal behavior, while others found the opposite association. To the best of our knowledge, there is no research in Portugal on the subject. Thus, our aim was to estimate the impact of the Portuguese economic crisis of 2009-2014 on the death rate by suicide and self-inflicted injury in Portugal.

Methods:
A retrospective ecological study with an interrupted time series analysis of deaths by suicide and self-inflicted injury (data from the National Statistics Institute) in mainland Portugal, in 2003Portugal, in -2014 performed. Resident population data was also retrieved from the National Statistics Institute. Binomial negative generalized linear models were used to compare rates and trends before (2003-2008) and during (2009-2014) the economic crisis. All rates were stratified and adjusted for seasonality.

Results:
The economic crisis was associated with 13% a step increase in the death rate due to suicide and self-inflicted injury, with unemployment playing a significant mediating role, being negatively associated to the outcome. Differences between groups exist, with males, working-age groups and the North and Centre regions being the most impacted, globally.

Conclusions:
Economic downturns pose risks for suicidal behavior. Unemployment may play a role in this association. Employment protection schemes can prevent this impact, so urgent action is needed to prevent economic crisis leading to additional suicides, especially in the context of the COVID-19 pandemic and the economic crisis it caused. Key messages: The Portuguese economic crisis of 2009-2014 was associated with an increased death rate due to suicide, especially in males, working-age groups and the North and Centre regions. Unemployment may play a role in this association, and active labour market programmes can prevent the negative impacts of economic crisis leading to additional suicides.

Background:
Educational inequalities in major depressive disorder (MDD) pose a major challenge. Tackling this issue requires evidence on the long-term impact of intervening on modifiable factors, e.g. behavioural and psychosocial factors. Therefore, we aim to simulate the development of educational inequalities in MDD across the life course, and to assess the impact of intervening on the modifiable factors that contribute to these inequalities.

Methods:
We used data from the prospective Dutch Lifelines Cohort Study to estimate the required input for a continuous-time iii107 microsimulation. The microsimulation allowed us to estimate the development of educational inequalities in MDD with a synthetic cohort of 500,000 individuals followed from ages 18 to 65, and to assess the potential benefit of intervening on quality of social contacts, health literacy, and smoking.

Results:
On average, an additional 19.1% of individuals with low education will ever experience MDD between ages 18 and 65 compared to those with high education (32.0% vs 12.9%, respectively). Additionally, individuals with low education generally will develop MDD 0.9 years earlier (35.6 years vs 36.5 years, respectively) and spend 1.2 years more with MDD (6.2 years vs 5 years, respectively), than individuals with high education. Improving the quality of social contacts in individuals with low education would have the largest impact; it would reduce the inequalities in the prevalence, onset, and duration of MDD by an average of 18.4%, 18.3%, and 28.6%, respectively.

Conclusions:
Intervening on modifiable factors, especially quality of social contacts, in individuals with low education could help reduce the large estimated educational inequalities in MDD over the life course.

Background:
Data comparing the populations' mental health from before, during and after the pandemic is needed. We aim to assess the risk factors for the first-onset and persistence of major depressive disorder (MDD) and suicidal thoughts and behaviours (STB) during the first year of the pandemic among the Spanish general population.

Methods:
Cohort study through two online surveys from before the pandemic (N = 2,005, October/November 2019) and 12months later (N = 1,357) on an adult Spanish, nationally representative, population-based sample. Multiple logistic regression models were used to assess the association between socio-demographic, COVID-19 related variables and healthcare received during the pandemic with the onset and persistence of MDD and STB.

Results:
Women have more than 3-fold risk for the onset (OR 3. increased the risk for STB onset, and being on sick-leave (OR 7.91; CI95% 1.80-34.66) for STB persistence.

Conclusions:
During the COVID-19 pandemic, women were consistently more at risk of having worse mental health than men. Direct and indirect consequences caused or aggravated by the pandemic are common risk factors for the increased risk for the onset and persistence of both MDD and STB. Identification of high-risk subgroups and risk factors for MDD and STB among the Spanish general population will allow the developing and implementing of evidence-driven strategies for reducing the long-term impact of the pandemic in populations' mental health. Key messages: The pandemic consequences, whether due to having had COVID-19, having close people affected or who have died from the infection and the social consequences increase the risk for worse mental health. Evidence-driven strategies for reducing the long-term impact of the pandemic in populations' mental health should be a public health priority.
Loneliness is widely acknowledged as a growing public health concern, accelerated by the onset of the COVID-19 pandemic. However, our knowledge about the effectiveness of interventions to reduce loneliness across the lifespan, including knowledge of different intervention strategies, is limited. This preregistered systematic review and meta-analysis aimed to evaluate the effect of interventions to reduce loneliness. The systematic review identified 136 studies. The meta-analysis included 128 studies comprising 54 randomised controlled trials (RCTs) (n = 6,379), 23 multi-cohort studies (n = 2,882) and 48 single-cohort studies (n = 3,009). A small to moderate statistically significant effect was detected (RCTs; SMD = -0.47, multi-cohort studies; SMD = -0.24, single cohortstudies; SMD = -0.42). Using the GRADE system, confidence in the estimates was assessed as low or very low, implying that the estimates may potentially be higher or lower. No statistically significant differences were found between age groups. Psychological treatment, social support interventions, and social and emotional skills training appeared to be the most effective intervention strategies in reducing loneliness but there is currently no strong reason to prefer one intervention strategy over another. Further analyses demonstrated that the long-term effects (i.e., one to six months after the intervention) were comparable to the short-term effects (i.e., up to four weeks after the intervention). Findings from the current metaanalyses provide overall evidence of the effectiveness of loneliness interventions. Given methodological limitations, including the heterogeneity of the reviewed studies, it remains unclear who the interventions would help the most. Overall, there is a need for rigorous and high-quality development and evaluations of interventions for loneliness.