Abstract
Developed countries have been related to a higher prevalence of mental disorders. This led us to hypothesize that cultural values typical of developed countries could be associated with mental disorders. Here, we sought to determine the association of indulgence (seeking momentary pleasure and freely expressing oneself) and individualism (being able to deviate from in-group norms) with the burden of four mental disorders: depressive, bipolar, anxiety, and eating disorders. We controlled for socio-economic factors (socio-demographic development, income inequality, and unemployment rate), negative life experiences, quality of health care systems, and quality of measurements. We also included world regions fixed effects to account for unobserved geo-spatial factors clustered at the regional level. Our sample included ninety-seven countries. Fully adjusted models revealed that indulgence was associated with an increase in the burden of all four disorders (p < 0.05). A 30 points increase in the indulgence dimension (from Italy = 47 to the UK = 77) was associated with an increase in DALYs by 8.4% (depressive disorders) to 21.0% (eating disorders). Other factors did not demonstrate any such systematic association. Developed nations may be exposed to mental disorders due to socio-cultural factors: seeking pleasure and freedom might be deleterious to population-level mental health.
This is a preview of subscription content, access via your institution.


Data availability materials and/or Code availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
Adebisi, A. (2020). Comment on ‘The vulnerability paradox in global mental health and its applicability to suicide.’ The British Journal of Psychiatry: The Journal of Mental Science, 217(5), 653–654. https://doi.org/10.1192/bjp.2020.185
Agbayani-Siewert, P., Takeuchi, D. T., & Pangan, R. W. (1999). Mental Illness in a Multicultural Context. In C. S. Aneshensel & J. C. Phelan (Eds.), Handbook of the Sociology of Mental Health (pp. 19–36). Springer US. https://doi.org/10.1007/0-387-36223-1_2
Barbalat, G., & Franck, N. (2020). Ecological study of the association between mental illness with human development, income inequalities and unemployment across OECD countries. British Medical Journal Open, 10(4), e035055. https://doi.org/10.1136/bmjopen-2019-035055
Barbalat, G., & Liu, S. (2021). Socio-demographic development and burden of mental, substance use disorders, and self-harm: An ecological analysis using the Global Burden of Disease study 2019. Australian & New Zealand Journal of Psychiatry, 00048674211066764. https://doi.org/10.1177/00048674211066764
Bergsma, A., & Veenhoven, R. (2011). The happiness of people with a mental disorder in modern society. Psychology of Well-Being: Theory, Research and Practice, 1(1), 2. https://doi.org/10.1186/2211-1522-1-2
Beugelsdijk, S., & Welzel, C. (2018). Dimensions and dynamics of national culture: Synthesizing Hofstede with Inglehart. Journal of Cross-Cultural Psychology, 49(10), 1469–1505.
Brand-Correa, L., Brook, A., Büchs, M., Meier, P., Naik, Y., & O’Neill, D. W. (2022). Economics for people and planet—moving beyond the neoclassical paradigm. The Lancet Planetary Health, 6(4), e371–e379. https://doi.org/10.1016/S2542-5196(22)00063-8
Bromet, E., Andrade, L. H., Hwang, I., Sampson, N. A., Alonso, J., De Girolamo, G., …, Iwata, N. (2011). Cross-national epidemiology of DSM-IV major depressive episode. BMC Medicine, 9(1), 1–16.
Dückers, M. L., Alisic, E., & Brewin, C. R. (2016). A vulnerability paradox in the cross-national prevalence of post-traumatic stress disorder. The British Journal of Psychiatry, 209(4), 300–305.
Dückers, M. L., & Brewin, C. R. (2016). A paradox in individual versus national mental health vulnerability: Are higher resource levels associated with higher disorder prevalence? Journal of Traumatic Stress, 29(6), 572–576.
Dückers, M. L., Reifels, L., De Beurs, D. P., & Brewin, C. R. (2019). The vulnerability paradox in global mental health and its applicability to suicide. The British Journal of Psychiatry, 215(4), 588–593.
Fischer, R., & Boer, D. (2011). What is more important for national well-being: Money or autonomy? A meta-analysis of well-being, burnout, and anxiety across 63 societies. Journal of Personality and Social Psychology, 101(1), 164.
Gallup, G. J. (Ed.). (2004). The Gallup Poll: Public Opinion 2003 (2003rd edition). Rowman & Littlefield Publishers.
Garhammer, M. (2002). Pace of life and enjoyment of life. Journal of Happiness Studies, 3(3), 217–256. https://doi.org/10.1023/A:1020676100938
Garschagen, M., Hagenlocher, M., Comes, M., Dubbert, M., Sabelfeld, R., Lee, Y. J., et al. (2016). World Risk Report 2016. Bündnis Entwicklung Hilft and UNU-EHS. http://collections.unu.edu/view/UNU:5763. Accessed 17 Oct 2022
Global Health Data Exchange (2020a). GBD Results Tool. Retrieved 2 August 2020a, from http://ghdx.healthdata.org/gbd-results-tool
Global Health Data Exchange (2020b). Global Burden of Disease Study 2019 (GBD 2019) Data Input Sources Tool. Retrieved 2 February 2021, from http://ghdx.healthdata.org/gbd-2019/data-input-sources
Global Health Data Exchange (2020c). Global Burden of Disease Study 2019 (GBD 2019) Socio-Demographic Index (SDI) 1950–2019 [Data set]. Institute for Health Metrics and Evaluation (IHME). https://doi.org/10.6069/D8QB-JK35
Heim, E., Maercker, A., & Boer, D. (2019). Value orientations and mental health: A theoretical review. Transcultural Psychiatry, 56(3), 449–470. https://doi.org/10.1177/1363461519832472
Heim, E., Wegmann, I., & Maercker, A. (2017). Cultural values and the prevalence of mental disorders in 25 countries: A secondary data analysis. Social Science & Medicine, 189, 96–104. https://doi.org/10.1016/j.socscimed.2017.07.024
Hofstede, G. (2010). Cultures and organizations: Software of the mind: Intercultural cooperation and its importance for survival /. McGraw-Hill.
Horton, R. (2018). Offline: NCDs, WHO, and the neoliberal utopia. The Lancet, 391(10138), 2402. https://doi.org/10.1016/S0140-6736(18)31359-X
Horwitz, A. V., & Wakefield, J. C. (2006). The epidemic in mental illness: Clinical fact or survey artifact? Contexts, 5(1), 19–23. https://doi.org/10.1525/ctx.2006.5.1.19
Inglehart, R. (1997). Modernization and postmodernization in 43 societies. Princeton University Press.
Institute for Health Metrics and Evaluation (2014). GBD protocol. Institute for Health Metrics and Evaluation. https://www.healthdata.org/gbd/about/protocol. Accessed 27 Oct 2022
Jorm, A. F. (2006). National surveys of mental disorders: Are they researching scientific facts or constructing useful myths? Australian & New Zealand Journal of Psychiatry, 40(10), 830–834. https://doi.org/10.1080/j.1440-1614.2006.01901.x
Jorm, A. F., Patten, S. B., Brugha, T. S., & Mojtabai, R. (2017). Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry, 16(1), 90–99. https://doi.org/10.1002/wps.20388
Jorm, A. F., & Ryan, S. M. (2014). Cross-national and historical differences in subjective well-being. International Journal of Epidemiology, 43(2), 330–340. https://doi.org/10.1093/ije/dyt188
Kapitány-Fövény, M., Richman, M. J., Demetrovics, Z., & Sulyok, M. (2018). Do you let me symptomatize? The potential role of cultural values in cross-national variability of mental disorders’ prevalence. International Journal of Social Psychiatry, 64(8), 756–766. https://doi.org/10.1177/0020764018811361
Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual Review of Public Health, 34, 119–138.
Knyazev, G. G., Kuznetsova, V. B., Savostyanov, A. N., & Dorosheva, E. A. (2017). Does collectivism act as a protective factor for depression in Russia? Personality and Individual Differences, 108, 26–31. https://doi.org/10.1016/j.paid.2016.11.066
Kohrt, B. A., Rasmussen, A., Kaiser, B. N., Haroz, E. E., Maharjan, S. M., Mutamba, B. B., …, Hinton, D. E. (2014). Cultural concepts of distress and psychiatric disorders: Literature review and research recommendations for global mental health epidemiology. International Journal of Epidemiology, 43(2), 365–406.
Lane, R. E. (2001). The Loss of Happiness in Market Democracies (New edition). Yale University Press.
de León, E. A., Shriwise, A., Tomson, Gö., Morton, S., Lemos, D. S., Menne, B., & Dooris, M. (2021). Beyond building back better: Imagining a future for human and planetary health. The Lancet Planetary Health, 5(11), e827–e839. https://doi.org/10.1016/S2542-5196(21)00262-X
Maercker, A. (2001). Association of cross-cultural differences in psychiatric morbidity with cultural values: A secondary data analysis. German Journal of Psychiatry, 4(1), 19–23.
Murray, C. J. L. (2022). The Global Burden of Disease Study at 30 years. Nature Medicine, 28(10), 2019–2026. https://doi.org/10.1038/s41591-022-01990-1
Nestle, M. (2019). How neoliberalism ruins traditional diets and health. The Lancet Diabetes & Endocrinology, 7(8), 595. https://doi.org/10.1016/S2213-8587(19)30142-1
Patel, V., Chisholm, D., Dua, T., Laxminarayan, R., & Medina-Mora, M. E. (Eds.). (2016). Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, Third Edition (Volume 4). Washington (DC): The International Bank for Reconstruction and Development / The World Bank. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK361945/
Rego, A., & Cunha, M. P. (2009). How individualism–collectivism orientations predict happiness in a collectivistic context. Journal of Happiness Studies, 10(1), 19–35. https://doi.org/10.1007/s10902-007-9059-0
Ruscio, A. M., Hallion, L. S., Lim, C. C. W., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., …, Scott, K. M. (2017). Cross-sectional Comparison of the Epidemiology of DSM-5 Generalized Anxiety Disorder Across the Globe. JAMA Psychiatry, 74(5), 465–475. https://doi.org/10.1001/jamapsychiatry.2017.0056
Ryder, A. G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S. J., & Bagby, R. M. (2008). The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America? Journal of Abnormal Psychology, 117(2), 300.
Schomerus, G., & Angermeyer, M. C. (2021). Blind spots in stigma research? Broadening our perspective on mental illness stigma by exploring ‘what matters most’ in modern Western societies. Epidemiology and Psychiatric Sciences, 30. https://doi.org/10.1017/S2045796021000111
Sierra-Siegert, M., & David, A. S. (2007). Depersonalization and Individualism: The Effect of Culture on Symptom Profiles in Panic Disorder. The Journal of Nervous and Mental Disease, 195(12), 989–995. https://doi.org/10.1097/NMD.0b013e31815c19f7
Stevens, G. A., Alkema, L., Black, R. E., Boerma, J. T., Collins, G. S., Ezzati, M., …, Welch, V. (2016). Guidelines for Accurate and Transparent Health Estimates Reporting: The GATHER statement. The Lancet, 388(10062), e19–e23. https://doi.org/10.1016/S0140-6736(16)30388-9
Tafarodi, R. W., & Smith, A. J. (2001). Individualism–collectivism and depressive sensitivity to life events: The case of Malaysian sojourners. International Journal of Intercultural Relations, 25(1), 73–88. https://doi.org/10.1016/S0147-1767(00)00043-2
The World Bank. (2021). Unemployment, total (% of total labor force) (modeled ILO estimate) | Data. Retrieved 15 January 2021, from https://data.worldbank.org/indicator/SL.UEM.TOTL.ZS
Tocqueville, A. de. (2012). Democracy in America (1st edition; H. C. Mansfield & D. Winthrop, Trans.). University of Chicago Press.
Twenge, J. M. (2002). Birth cohort, social change, and personality: The interplay of dysphoria and individualism in the 20th century. Advances in personality science (pp. 196–218). Guilford Press.
Veenhoven, R. (1999). Quality-of-life in individualistic society. Social Indicators Research, 48(2), 159–188. https://doi.org/10.1023/A:1006923418502
Veenhoven, R. (2010). Life is getting better: Societal evolution and fit with human nature. Social Indicators Research, 97(1), 105–122. https://doi.org/10.1007/s11205-009-9556-0
Vos, T., Lim, S. S., Abbafati, C., Abbas, K. M., Abbasi, M., Abbasifard, M., …, Murray, C. J. L. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396(10258), 1204–1222. https://doi.org/10.1016/S0140-6736(20)30925-9
Webb, R. T., & Lorant, V. (2018). Neoliberal welfare reform and single parents’ mental health. The Lancet Public Health, 3(7), e307–e308. https://doi.org/10.1016/S2468-2667(18)30116-6
WID - World Inequality Database. (2021). World Inequality Database. Retrieved 14 January 2021, from WID website: https://wid.world/data/
Wilkinson, R. G., & Marmot, M. G. (2003). Social determinants of health: The solid facts. World Health Organization. https://doi.org/10.13016/yroj-yfcz
Wilkinson, R. G., & Pickett, K. E. (2009). Income inequality and social dysfunction. Annual Review of Sociology, 35, 493–511.
Acknowledgements
We wish to acknowledge the contribution of the GBD collaborator network in providing the disease burden estimates, which we downloaded from their publicly available data source (http://ghdx.healthdata.org/gbd-results-tool). The GBD network was not consulted nor involved in this paper.
Author information
Authors and Affiliations
Contributions
GB has conceived the study and extracted the data. GB and SL have analysed and interpreted the data, drafted the paper and revised it. Both authors have approved the submitted version and have agreed to be personally accountable for the accuracy and integrity of any part of the work.
Corresponding author
Ethics declarations
Ethics approval, Consent
This research did not involve human participants. Therefore, ethical approval and consent were deemed not necessary.
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Barbalat, G., Liu, S. Country-level association of socio-cultural factors with the burden of four common mental disorders. An ecological analysis using the Global Burden of Disease database. Curr Psychol (2022). https://doi.org/10.1007/s12144-022-04065-z
Accepted:
Published:
DOI: https://doi.org/10.1007/s12144-022-04065-z