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Inequality: an underacknowledged source of mental illness and distress

  • Kate E. Pickett (a1) and Richard G. Wilkinson (a2)


Greater income inequality is associated with higher prevalence of mental illness and drug misuse in rich societies. There are threefold differences in the proportion of the population suffering from mental illness between more and less equal countries. This relationship is most likely mediated by the impact of inequality on the quality of social relationships and the scale of status differentiation in different societies.

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Kate E. Pickett, Department of Health Sciences, University of York, Seebohm Rowntree Building, Area 2, Heslington, York YO10 5DD, UK. Email:


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Inequality: an underacknowledged source of mental illness and distress



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Inequality: an underacknowledged source of mental illness and distress

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Inequality, mental health and research

David Harper, Reader in Clinical Psychology
09 February 2011

Pickett and Wilkinson (2010) are to be congratulated for directing our attention to the pervasive effects of social inequality on mental health and suggesting interventions targeted at the global, national and community level - rather than solely at the individual therapy level, as health professionals are inclined to do.

Whilst we agree that there is much evidence to link inequality and mental health we would like to offer some suggestions for future research in this area. One of the problems with psychiatric epidemiology, as Rogersand Pilgrim (2003) have noted, is that it draws on heterogeneous, contested categories which often have considerable problems of reliabilityand validity (Boyle, 2002). For researchers to make clearer links betweeninequality and mental distress it will be important to conduct studies which gather information on particular kinds of problematic experience -- what some authors refer to as complaints (Bentall, 2004) or symptoms.

We also need to re-conceptualise mental health as not simply a categorical variable which is either absent or present, but something thatexists along a continuum, across a number of dimensions, which is influenced by context, and has a particular set of individual and culturalmeanings. Obviously, given the increasing globalised medicalisation of distress the thresholds need to be set much higher than they are currentlyso that only clinically significant distress is captured. There is also a need to draw on systematic qualitative investigations that enable the context and meaning of distress and inequality to be understood (e.g. Charlesworth, 1999). This might also be extended to examine how those who are wealthy live with the privileges that wealth brings.

Lastly, as Pickett and Wilkinson note, there are a number of candidate causal hypotheseses. However, there is remarkably little research into models that link inequality and distress. One of the problems with the explanations Pickett and Wilkinson cite is that they tend to over-emphasise psychological variables, potentially obscuring the significant contribution of actual social and material conditions. Research needs to be guided by rigorous psychosocial models that do not dualistically separate the psychological from other influences.

David Harper, Reader in Clinical Psychology, University of East London

John Cromby, Senior Lecturer, Loughborough University


Bentall, R.P. (2004). Madness Explained: Psychosis And Human Nature Allen Lane/Penguin: London.

Boyle, M. (2002). Schizophrenia: A Scientific Delusion? Second edition. London: Routledge.

Charlesworth, S.J. (1999). A Phenomenology Of Working-Class Experience. London: Cambridge University Press.

Pickett, K.E. & Wilkinson, R.G. (2010). Inequality: an underacknowledged source of mental illness and distress. British Journal of Psychiatry, 197, 426–428.

Rogers, A. & Pilgrim, D. (2003). Mental Health and Inequality. Basingstoke: Palgrave MacMillan.
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Conflict of interest: None Declared

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"Income inequality and mental health problems"

derek a summerfield, consultant psychiatrist/Hon Sen Lect
26 January 2011

I thank Prof Pickett for her response to my letter. My quarrel is indeed not with her and her co-author but with the WHO-backed epidemiologythat has produced frankly incredible population prevalences for mental disorder like 1 in 4. My quarrel is also with a biomedically driven psychiatric academe and with profession leaders like the Royal College of Psychiatrists who self-aggrandisingly endorse such figures. From what ProfPickett says, the correlations she is identifying apply whether the comparison is with “distress”, “mental health problems” or “mental illness”, but for the psychiatric profession maintaining such distinctionsis crucial for its very credibility. (Not long ago I asked Sir David Goldberg, originator of perhaps the most widely used screening instrument the GHQ, what he had intended to capture with it. “Distress”, he replied. But distress” is not “mental illness”.) These concepts are increasingly blurred by cultural trends towards medicalisation of everyday life, endorsing a view of the average citizen as ever less robust and more vulnerable. Psychiatry seems uncritically to support this process, which will do no one any good in the longer run across society.

My reflections were not intended to question the thrust of the work on income inequality and health, which as I said has built up a near unassailable body of evidence, merely to query how much the slope of the graph might have been steepened by apparently stronger trends towards the medicalisation of nonspecific distress in the English speaking world by comparison with other cultures.

Finally, I wish I could share Prof Pickett's apparent optimism that greater equality is achievable. To reverse the income inequality that has been deepening in UK since the late 1970s would take more than mere governmental tinkering, since we are all anchored to an economic system whose intrinsic thrust runs implacably the other way, particularly in its neoliberal form. To alter this will take a revolution!
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Inequality, deprivation and psychosis

Rob Poole, Professor of Mental Health
24 January 2011

Pickett and Wilkinson’s editorial on the public health impact of income inequality1 is a timely reminder that there are preventative measures that can be taken to improve the mental health of the UK population, and that these need not involve the daunting, and perhaps impossible , task of mass individual intervention to attempt to induce change at a population level. Like their excellent book, The Spirit Level,2 their article does not explore the relationship between psychosis and social deprivation, perhaps because the association is complex.

There is strong evidence that the prevalence of psychosis is especially high amongst deprived inner city populations. Despite the fact that psychiatrists generally regard psychosis as a genetic or biological disorder, the association between prevalence and deprivation may be at least as strong (if not stronger) for psychosis as for depression3. Although older studies have suggested that this may be due to social drift, more recent studies of place of birth4, and of the mental health ofthe offspring of migrants5, strongly suggest that environmental factors related to social deprivation play a major aetiological role.

At present it is not clear whether social inequality or specific types of deprivation are the relevant factor. People who have grown up in rural deprivation appear to have a lower risk of becoming psychotic than their urban compatriots6, which suggests that specific types of deprivation might be more relevant. The psychological mechanisms linking social inequality (rather than wealth) in childhood to mental health are also poorly understood. Presumably the feeling of being relatively socially disadvantaged must involve some kind of negative comparison against a reference group. As Pickett and Wilkinson’s work finds effects over large geographical areas, rather than locally, it seems likely that beliefs about one’s status in society as a whole are important.

These are complications, but not necessarily contradictions, with regard to Pickett and Wilkinson’s central contention that inequality is the important factor. In any case, the current state of knowledge leads usto the same conclusion: the nation’s mental health would be likely to improve if our society was more equal than it is at present.

Rob Poole, Professor of Mental Health, Glyndwr University, Wrexham.

Richard Bentall, Professor of Clinical Psychology, University of Liverpool.

Declaration of interests: none


1.Pickett K, Wilkinson R. (2010), Inequality: an underacknowledged source of mental illness and distress. British Journal of Psychiatry 197,426-428.

2.Wilkinson R, Pickett K. (2009) The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Allen Lane.

3.Sundquist K, Gõlin F, Sundquist J. (2004) Urbanisation and incidence of psychosis and depression. British Journal of Psychiatry. 184,293-298.

4.Harrison G, Gunnell D, Glazebrook C, Page K, Kwiecinski R. (2001) Association between schizophrenia and social inequality at birth: case-control study. British Journal of Psychiatry. 179, 346-350.

5.Hutchinson G, Takei N, Fahy TA, Bhugra D, Gilvarry C, Moran P, Mallett R, Sham P, Leff J, Murray RM. (1996) Morbid risk of schizophrenia in first degree relatives of White and African-Caribbean patients with psychosis. British Journal of Psychiatry. 169, 776-780.

6.Lewis G, David A, Andréasson S, Allebeck P. (1992) Schizophreniaand city life. Lancet. 340, 137-140.
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Conflict of interest: None Declared

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Preventing the inequality gap widening: the role of the General Practitioner

Trisha Sivaraman, Medical Student
22 December 2010

Dear Editor,

Pickett and Wilkinson discuss how mental health and drug use is more prevalent in countries with higher income inequalities [1]. They suggest a possible solution to this problem, by redistributing income through taxes and benefits, and finding ways to reduce income differences in market incomes before taxes [1]. However, how practical and feasible this solution is in the near future is debatable. The inequality gap continues to widen, and it is important that all is done in our power as asociety to bring this to a halt.

At any one time, one in six people of working age have a mental health problem, most often anxiety or depression. About a third of all GP consultations involve a major element of mental health [2]. Primary care therefore plays a crucial role in mental health, especially since there are likely to be a number of people with mental health problems that remain undiagnosed.

In order to tackle health inequalities most effectively, the government has used the Spearhead approach, where most effort is directed at the most disadvantaged areas [3]. A study carried out this year used data from the Quality and Outcomes Framework (QOF) for 2004/05 and 2005/06and found that practices in Spearhead PCTs performed worse than practices in non-Spearhead PCTs in England between 2004-2006 but showed greater improvement [4]. The narrowing in performance between practices in Spearhead and non-Spearhead PCTs may have indirectly contributed to a reduction in area-based health inequalities but the differences are small.

The results from this study show that there is still much potential for area-based initiatives to have an impact and general practitioners need to tailor their care to the particular community they are working with. A nationally representative cross-sectional study carried out this year found income-related inequalities in the prevalence of psychological distress were greatest in midlife; in women aged 45-54 years the odds ratio of reporting mental illness in the lowest income group compared withthe highest was 10.25 [5]. Therefore a possible strategy is GPs spending more time screening this age group and social class in particular for any signs of mental illness and hence tackle any problems before they progress.

We agree that the suggestions of Pickett and Wilkinson could be effective, but it is important to also aim for goals that can be achieved quickly and reach the people who really need it, and the best place to start is in the community. The primary care setting is invaluable in identifying and managing risk factors in groups most at risk of developingmental disorders. Individuals from lower socio-economic backgrounds are the least assertive and proactive about their health, and general practitioners should make it a point to screen these individuals during routine check-ups and to even invite them for specific check-ups if they are particularly at risk. This may prevent these individuals from sliding further down the social scale, and in this way GPs could play a crucial role in preventing the inequality gap from widening.

Trisha Sivaraman4th Year Medical StudentSt. George’s University of London

Denosshan Sri5th Year Medical StudentUniversity of Cambridge

Correspondence to: Trisha Sivaraman

Disclosure of interests:No conflict of interests.


1.Inequality: an underacknowledged source of mental illness and distress. Pickett K, Wilkinson R. Br J Psychiatry 2010;197:426-82.MIND 2010. Treatments and services for people with mental health problems. Available at:

3.Great Britain. Department of Health (2008) Health inequalities: progress and next steps: progress and next steps. [Online]. Available at: A, Khachatryan A, Gilmour S. Does general practice reduce health inequalities? Analysis of quality and outcomes framework data. Eur J Public Health. 2010 Dec 8. [Epub ahead of print]5.Lang IA, Llewellyn DJ, Hubbard RE, Langa KM, Melzer D. Income and the midlife peak in common mental disorder prevalence. Psychol Med. 2010 Dec 10:1-8. [Epub ahead of print]
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Re: Income inequality and mental health problems

Kate E Pickett, Professor of Epidemiology
17 December 2010

Derek Summerfield suggests that the World Health Organization (1) and other survey data that we use seem ‘preposterous’ to him as a doctor and a citizen. His quarrel is then not with us but with the psychometric testing of the diagnostic interviews used by WHO and other epidemiological surveys of mental illness. But even in terms of our own personal experience, we are not at all surprised at the 23% annual period prevalence of any mental illness in the UK. Many of us have felt incapacitated by depression or anxiety, and among our acquaintances we can count episodes of self harm, eating disorders, addictions, behaviour problems and autistic spectrum disorders. As we mentioned in our paper, episodes of severe mental illness are also strongly correlated with income inequality. (2) Both sets of data suggest that inequality is related to mental health, however we choose to label the symptoms.

It is wrong to suggest that the correlations reflect only the high measured prevalence of mental illness in the English speaking countries. Although the English speaking countries do indeed have higher prevalence of mental illness, and higher levels of income inequality, they are not outliers and do not appear to represent a distinct group: they are simply the countries at one end of the distribution. Indeed if we look only at the sub-sample of the English speaking countries, income inequality remains significantly correlated, and is an important explanatory factor for mental illness just among them (r=0.95, p=0.01).

It would be odd if the relationships we showed with mental illness existed in a vacuum but of course they do not. Our research focuses on problems with social gradients, and we find that more unequal societies also have lower levels of trust and social capital, poorer physical health, higher rates of obesity and teenage pregnancies and births, low child wellbeing, educational achievement and social mobility, and higher levels of violence and imprisonment.(3) Against that background it would be surprising if mental health was not also affected by wider income differences.

Until the rise of neoliberal economic policy in the 1980s, the UK was a much more equal society and it could be so again. We are optimistic that societies can change. There are numerous mechanisms through which governments and institutions can promote greater equality, and a wider recognition of the harm caused by inequality is an essential prerequisite.

The reality is that inequality causes real suffering – regardless of labels. Those of us concerned with the mental health of the public need to address its structural, as well as its individual context.

Declaration of Interest: NONE

1. Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Jama 2004;291(21):2581-90.

2. Pickett KE, Wilkinson RG. Inequality: an underacknowledged source of mental illness and distress. Br J Psychiatry 2010;197:426-8.

3. Wilkinson R, Pickett K. The Spirit Level: why more equal societies almost always do better. London: Penguin, 2009.
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Conflict of interest: None Declared

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Income inequality and mental health problems

derek a summerfield, consultant psychiatrist/hon sen lect
08 December 2010

Pickett and Wilkinson’s paper in the BJP is the latest in a series ofpersuasive publications on income inequality and health stretching back tothe 1990s. (1) However, in relation to what they variously call “mental illness”, “mental health problems” and “distress”, I wonder if they are taking at face value the highly inflated prevalence findings they cite. They write that “one million British schoolchildren- one in ten between the ages of 5 and 16- are mentally ill” and that “one in four adults have been mentally ill in the past year” in both USA and UK. These mostly represent the so-called common mental disorders. These figures are preposterous- as much to the citizen in me as to the psychiatrist- and make an urgent case for the profession to go back to the drawing board to revisit the core question: just what exactly do we mean by a ‘mental disorder’? Quantitative surveys tend to re-cast the epiphenomenal features of situational distress as free-standing disorder, so cannot but recruit false positives on a systematic scale. (2)

The authors have plotted 12 countries onto a graph of “percentage with any mental illness” versus “income inequality”, and it seems noteworthy that the strongest correlations are, successively, USA, UK, Australia, New Zealand, and Canada. Below is France and, much lower down,Netherlands, Belgium, Spain, Germany, Japan, and Italy. I wonder why thereis this apparent split between English speaking countries and the rest, and whether this reflects particularities in the Anglo-american world, both in psychiatric culture and in trends towards the psychiatrisation of everyday life which may be less advanced elsewhere. Taking account of possible skews of this kind would be likely to make the graph line rather less steep. Could the authors comment?

The authors acknowledge that a possible confounder in comparing ratesof mental illness from one society to another lies in differing recognition and interpretation of survey questions, but go on to make the point that “at least the same diagnostic interviews are used in each country”. I’m afraid this is to re-state the problem, which is one of validity, rather than resolve it. Valid research methods must reflect the “nature of reality” for subjects and a standard questionnaire used across heterogeneous societies cannot do this.

Lastly, Pickett and Wilkinson conclude that if the UK is to reverse the massive rise in inequality experienced during the 1980s, “we need to encourage all mechanisms that help to reduce income differences.” But are we not all stuck with an intractable feature of late capitalism, its structural tendency to stratify incomes rather than to level them out?

1 Inequality: an underacknowledged source of mental illness and distress. Pickett K, Wilkinson R. Br J Psychiatry 2010;197:426-8.2Cross-cultural perspectives on the Medicalization of Human Suffering. Summerfield D. In: Posttraumatic Stress Disorder. Issues and Controversies(ed G Rosen). Chichester: John Wiley, 2004.

Derek Summerfield, Institute of Psychiatry, King’s College, London, UK
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