Population Health


Social and Economic Determinants of Mental and Cognitive Health

Maarten Jacob Bijlsma, Karen van Hedel, Pekka Martikainen, Kieron Barclay; in Collaboration with Ben Wilson (Stockholm University, Sweden), Irma Elo (University of Pennsylvania, USA), Kathleen Cagney (University of Chicago, USA)

Detailed description:

Depression is a leading contributor to the global burden of disease, with a lifetime prevalence of 10% to 15% worldwide. The effects of depression extend far beyond its direct symptoms to a greatly increased risk of suicide and, possibly, of cardiac death.

Various methodological problems must be overcome when seeking to disentangle the relationship between depression and unemployment. The issue of intermediate confounding is especially important in a mediation analysis with longitudinal data. Unfortunately, methods for dealing with these issues appropriately have not yet been widely adopted, and intermediate confounding has been largely ignored. We applied the G-formula (a method that can account for potentially biasing influences such as intermediate confounding) to decompose the population-level hazard ratio of (un)employment on purchasing an antidepressant into its controlled direct effect and the pathways via income, household status, and other health conditions. We applied this approach to an 11% random sample of register data from Finland (1996 to 2007), and in particular to young individuals aged 16 to 35.

Using the G-formula, we investigated a scenario in which unemployed individuals were instead provided with employment. We found that in this scenario, the population-averaged hazard of first antidepressant purchase decreased by 7.6%. Of this reduction, 61% was mediated, operating primarily through changes in income and household status, while mediation through (other) health conditions was negligible. The direct effect of this hypothetical intervention was therefore 39%. These results show that after taking complex interdependencies into account, eliminating unemployment raises income levels and promotes family formation among young adults, which in turn decreases antidepressant consumption. There are also large direct effects of unemployment on antidepressant consumption.

Marriage is generally associated with better mental health, but less is known about the mental-health effects of cohabitation. We conducted a study to assess how cohabiting young adults differ from married and single young adults in terms of their psychotropic medication purchases in Finland, a Nordic country where the trend toward cohabitation started early, and current levels of cohabitation are high. We used panel data from an 11% random sample of the population residing in Finland for the years 1995 to 2007, with annual measurements of all covariates. Ordinary least squares (OLS) and individual fixed-effects (FE) models were applied to disentangle the relation between cohabitation and purchases of prescribed psychotropic medication, while controlling for relevant time-varying factors, such as age, education, economic activity, and number of children.

Overall, our results showed that both cohabiting men and women had worse mental health than married men and women. However, controlling for observed and unobserved differences between cohabiting and married individuals removed this mental health disadvantage of cohabiters. But single men and women were still disadvantaged, which suggests that selection into partnership does not fully explain the mental-health disadvantage of single individuals. Thus, adequate interventions and policies to improve the singles’ mental health may be needed. Our results nevertheless suggest that cohabitation provides mental health benefits similar to marriage in a context where cohabitation is the norm, at least for young adults.

Research keywords: Economics, Employment, Retirement; Family Behavior; Health Care, Public Health, Medicine, and Epidemiology; Life Course; Psychology

Region keywords: China; Europe; Finland


van Hedel, K.; Martikainen, P.; Moustgaard, H.; Myrskylä, M.:
SSM-Population Health 4, 244-253 (2018).
Bijlsma, M. J.; Tarkiainen, L.; Myrskylä, M.; Martikainen, P.:
Social Science and Medicine 194, 142-150 (2017).
Moustgaard, H.; Joutsenniemi, K.; Martikainen, P.:
European Journal of Public Health 26:6, 1034-1039 (2016).