International Journal of

Environmental Research
and Public Health

Article
Gender Differences in the Prevalence of Mental Health,
Psychological Distress and Psychotropic Medication
Consumption in Spain: A Nationwide Population-Based Study
Clara Maestre-Miquel 1 , Ana López-de-Andrés 2, * , Zichen Ji 3 , Javier de Miguel-Diez 3 , Arturo Brocate 4 ,
Sara Sanz-Rojo 2 , Antonio López-Farre 5 , David Carabantes-Alarcon 2 , Rodrigo Jiménez-García 2
and José J. Zamorano-León 2

1 School of Health Sciences, Universidad de Castilla la Mancha, 45600 Talavera de la Reina, Spain;
Clara.Maestre@uclm.es
2 Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense
de Madrid, 28040 Madrid, Spain; ssanz01@ucm.es (S.S.-R.); dcaraban@ucm.es (D.C.-A.);
rodrijim@ucm.es (R.J.-G.); josejzam@ucm.es (J.J.Z.-L.)
3 Respiratory Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación



Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28040 Madrid, Spain;


jizich72@gmail.com (Z.J.); javier.miguel@salud.madrid.org (J.d.M.-D.)
Citation: Maestre-Miquel, C.; 4 Sport Science School, Universidad Castilla de la Mancha, 45071 Toledo, Spain; arturobrocate@gmail.com
5 Department of Medicine, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain;
López-de-Andrés, A.; Ji, Z.; de
Miguel-Diez, J.; Brocate, A.; antonio.lopez.farre@med.ucm.es
Sanz-Rojo, S.; López-Farre, A.; * Correspondence: anailo04@ucm.es
Carabantes-Alarcon, D.;
Jiménez-García, R.; Zamorano-León, Abstract: Background: To assess gender differences in the prevalence of self-reported mental disor-
J.J. Gender Differences in the ders, psychological distress and psychotropic drug consumption, and to identify sociodemographic
Prevalence of Mental Health, and health-related variables associated with these conditions in the male and female population
Psychological Distress and (aged ≥ 18 years). Methods: A cross-sectional study was carried on 22,141 subjects aged 18 and
Psychotropic Medication over, using data from the Spanish National Health Interview Survey 2017. Results: We found an
Consumption in Spain: A
overall prevalence of mental disorders, psychological distress and psychotropic drug consumption of
Nationwide Population-Based Study.
13.8%, 18.3% and 13.9%, respectively. After multivariable adjustment, women showed significantly
Int. J. Environ. Res. Public Health 2021,
increased probabilities of 1.74-fold for mental disorders, 1.26-fold for psychological distress and
18, 6350. https://doi.org/
10.3390/ijerph18126350
1.26-fold for psychotropic drug consumption compared to men. Variables such as gender, age, nation-
ality, marital status, educational level, self-rated health, the presence of different chronic disorders,
Academic Editor: Paul B. Tchounwou alcohol consumption and smoking habit were independently associated with mental disorders,
psychological distress and psychotropic drug consumption. Several variables showed a differential
Received: 22 April 2021 effect on mental health status and psychotropic drug consumption according to gender. Conclusions:
Accepted: 8 June 2021 Women suffer from mental disorders, experience psychological distress and consume psychotropic
Published: 11 June 2021 drugs significantly more than men in Spain. Possible explanations for these results may be related
to differences in emotional processing, willingness to report diseases and even intrinsic biological
Publisher’s Note: MDPI stays neutral traits. Screening for mental health status and psychotropic drug consumption should be considered,
with regard to jurisdictional claims in particularly in Spanish women, younger adults and individuals who are not married, are obese, have
published maps and institutional affil-
poor self-rated health, suffer from chronic diseases or have a smoking habit.
iations.

Keywords: mental health; psychological distress; psychotropic medication; sex differences; prevalence

Copyright: © 2021 by the authors.

Licensee MDPI, Basel, Switzerland. 1. Introduction
This article is an open access article
Mental health is considered to be a crucial marker of the overall wellbeing of individ-
distributed under the terms and
conditions of the Creative Commons
uals, societies and countries [1]. Regrettably, mental health problems are currently among
Attribution (CC BY) license (https://
the ten leading causes of disability in both developed and developing countries. Indeed,
creativecommons.org/licenses/by/
the World Health Organization has estimated that at least 10% of the world’s population
4.0/). have been diagnosed with different types of mental disorders, the most common being

Int. J. Environ. Res. Public Health 2021, 18, 6350. https://doi.org/10.3390/ijerph18126350 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 6350 2 of 15

anxiety and depression [1]. In particular, depression is ranked third in the global burden of
disease and is projected to rank first in 2030 [2].
The European Study of the Epidemiology of Mental Disorders (ESEMeD) is the widest
European study published on mental health [3]. This study reveals the high prevalence
of mental disorders in Europe, with up to 25.9% of Europeans having been diagnosed
with a mental disorder at some point in their life [4]. Historically, Spain is one of the
European countries with the lowest prevalence of major depressive episodes [5]. However,
recent findings have shown an increased incidence of mental disorders and psychological
distress in recent years in Spain [6–8]. As expected, psychotropic medication consumption
has progressively increased in Spain, particularly among women [9–11]. However, it is
important to note that different studies have suggested that mental disorders may not be
the only factor or even the most important factor behind this increment [12,13]. Several
works have reported a great difference between percentages of mental health diagnosis
and psychotropic drug consumption [14]. This means that other clinical and nonclinical
predisposing factors to psychotropic treatment should also be analyzed [11,14–16]. Inter-
estingly, the European economic recession seems to have had a particular impact on mental
healthcare, serving as a modulating and predisposing factor for mental disorders [17].
Several authors have highlighted the importance and utility of population health
surveys for monitoring psychological morbidity and identifying potential associations
between sociodemographic and/or health-related factors and psychiatric morbidity, allow-
ing to identify groups at risk of developing mental illness [11,15,16,18,19]. The Spanish
National Health Interview Survey (SNHIS) has been described as a useful instrument
for the epidemiological investigation of common mental disorders such as self-reported
depression and anxiety [19]. Interestingly, it can be also used to measure psychological
distress based on the 12-Item General Health Questionnaire (GHQ-12) [20], which has been
previously validated in Spanish and used on the general population and on populations
with chronic diseases [21–23].
Using the SNHIS 2017, the aims of the present work were to (i) assess gender
differences in the prevalence of self-reported mental disorders, psychological distress
(GHQ-12 ≥ 3) and self-reported psychiatric medication consumption and to (ii) identify
which sociodemographic and health-related variables are associated with reporting mental
disorders, psychological distress (GHQ-12 ≥ 3) and consumption of psychotropic medica-
tions in the male and female populations.

2. Materials and Methods

2.1. Study Design and Study Population
This is an epidemiological cross-sectional study. The data for our investigation were
obtained from the SNHIS 2017. Details on the methodology of the SNHIS 2017 are described
elsewhere [24,25].
The SNHIS 2017 was designed to provide reliable estimates, at both national and
regional levels, of the population living in Spain aged 15 years or over and included a total
of 23,089 participants. However, in accordance with considerations of psychotropic drug
prescription, we selected individuals aged ≥ 18 years, resulting in a study population of
22,141 subjects. The information collection period was from October 2016 to October 2017.
Briefly, the SNHIS 2017 uses three-stage sampling, the first stage being the census tracts,
the second the main family dwellings and the last stage involving the random selection
(Kish method) of an adult (aged ≥ 15 years old) within each household [24]. The method
used to collect the information is computer-assisted personal interview.

2.2. Study Variables

The variables included in the present study were selected based on questions related
to the variables of sociodemographic characteristics health status and use of health services
and to lifestyle behaviors. Details regarding the questions used to create our study variables
can be found in Table S1 and in the SNHIS 2017 methodology description [24,25].
Int. J. Environ. Res. Public Health 2021, 18, 6350 3 of 15

• Mental health status was measured using three dependent variables:

1. The self-reported presence of a “mental disorder”, defined as the person inter-
viewed reporting suffering from depression and/or anxiety, with these condi-
tions having been diagnosed by a medical professional;
2. The presence of “psychological distress”, assessed using the 12-item General
Health Questionnaire 12 (GHQ-12). The Spanish version of the GHQ-12 has been
validated, and a cutoff point of ≥3 is recommended to identify individuals with
psychological distress [20–23];
3. The variable “psychotropic drug consumption”, created using questions regard-
ing the self-reported use of physician-prescribed medications in the last two
weeks. We considered any of the following as psychiatric medications: “tran-
quilizers (anxiolytics)”, “sedatives (anxiolytics)”, “sleeping pills (anxiolytics)”
and “antidepressants”.
• Independent variables included were classified into four types:
(i) sociodemographic characteristics: “gender”, “age groups”, “nationality”, “marital
status”, “educational level” and “social class”; (ii) health status variables: “self-rated health”
and self-reported presence of medical-professional-diagnosed concomitant chronic diseases
(“hypertension”, “heart diseases”, “arthrosis”, “stroke”, “diabetes mellitus”, “malignant
tumors”, “respiratory diseases“, “chronic pain” and “accident permanent injuries”); (iii) use
of healthcare services in the last year (“emergency services”, “hospital admission”, “visit
to physiotherapist” and “visit to psychologist”); and (iv) lifestyle variables (“obesity”,
“alcohol consumption”, “current smoking habit” and “physical inactivity).
Detailed descriptions and categories for these variables are shown in Table S1.

2.3. Statistical Analysis

Qualitative variables were expressed as frequencies and percentages. Comparisons
were carried out using Chi-squared test. If the participant answered, “Don’t know” or
“Don’t answer”, they were excluded from the analysis of that variable. Multivariable analy-
ses were performed using logistic regression, generating three models, one model for each
dependent study variable. The models included variables with a significant association
in the bivariate analysis or reported as relevant in the literature. Odds ratios (OR) with
95% confidence intervals (CI) are provided as measures of association. We considered as
possible confounders of the multivariate logistic regression analysis the following variables:
age, nationality, marital status, education level and social class. Statistical analysis was
performed using the software SPSS 25.0. A p value < 0.05 was considered statistically
significant (two tails).

2.4. Ethical Aspects

In accordance with the Spanish legislation, as we used a public access dataset with
anonymous data, the approval of an ethics committee is waived. The database can be freely
downloaded by anyone from the Spanish Ministry of Health webpage [26].

3. Results
3.1. Distribution of Characteristics of the Study Population
The study population included a total of 22,141 participants aged 18 years or over
interviewed in the SNHIS 2017, which is considered a balanced population with respect to
gender, with percentages of 48.6% and 51.4% for men (n = 10,751) and women (n = 11,390),
respectively. As Figure 1 shows, crude prevalence of mental disorders (8.9% vs. 18.4%),
psychological distress (14.2% vs. 22.2%) and psychotropic drug consumption (9.3% vs.
18.1%) was significantly higher among women compared to men. These results indicate a
2.07-fold higher crude prevalence for mental disorders, 1.56-fold for psychological distress
and 1.95-fold for psychotropic medication consumption among women compared to men.
 11,390), respectively. As Figure 1 shows, crude prevalence of mental disorders (8.9% vs.
18.4%), psychological distress (14.2% vs. 22.2%) and psychotropic drug consumption
(9.3% vs. 18.1%) was significantly higher among women compared to men. These results
indicate a 2.07-fold higher crude prevalence for mental disorders, 1.56-fold for
Int. J. Environ. Res. Public Health 2021,psychological
18, 6350 distress and 1.95-fold for psychotropic medication consumption among4 of 15
women compared to men.

Figure
Figure 1.
1. Prevalence
Prevalence of
of variables of mental
variables of mental disorders,
disorders, psychological
psychological distress
distress and
and psychotropic
psychotropicdrug
drug consumption according to gender. * p value < 0.001 for the comparison between
consumption according to gender. * p value < 0.001 for the comparison between men and menwomen.
and
women.
3.2. Prevalence of Mental Health Disorders, Psychiatric Distress and Psychotropic Drug
Consumption
3.2. PrevalenceAccording
of MentaltoHealth
Sociodemographic Variables. Distress
Disorders, Psychiatric Comparison between Men Drug
and Psychotropic and Women
Consumption According to Sociodemographic Variables. Comparison between Men and Women
In Table 1, the prevalence of mental disorder, psychological distress and psychotropic
drugIn consumption
Table 1, is thepresented according
prevalence to sociodemographic
of mental variables fordistress
disorder, psychological each gender.
and
Mental disorders, psychological distress and psychotropic drug consumption
psychotropic drug consumption is presented according to sociodemographic variables forwere signifi-
cantly gender.
each associatedMental
with thedisorders,
sociodemographic variables
psychological of age, nationality,
distress marital status,
and psychotropic drug
education level and social class in the total population.
consumption were significantly associated with the sociodemographic variables of age,
nationality, marital status, education level and social class in the total population.
Table 1. Prevalence of mental disorders, psychologic distress and psychiatric drug consumption among men and women
according to sociodemographic
Table 1. Prevalence variables.psychologic
of mental disorders, Results from the Spanish
distress National Health
and psychiatric Interview Survey
drug consumption among2017.
men and women
according to sociodemographic variables. Results from the Spanish National Health Interview Survey 2017.
Mental Disorders Psychological Distress Psychotropic Drug Consumption
MenMentalWomen
Disordersp Value Psychological
Men WomenDistress Psychotropic
Men Drug
WomenConsumption
Variables p Value p Value
n (%)
Men n (%)
Women n (%)
Men n (%)
Women n (%)
Men n (%)
Women
Variables p Value p Value p Value
Age (years) a,b,c n (%) n (%) n (%) n (%) n (%) n (%)
18–37 a,b,c
Age (years) 154 (5.4) 254 (9.1) <0.001 314 (11.1) 482 (17.5) <0.001 107 (3.8) 131 (4.7) 0.098
38–49
18–37 232 (7.9)
154 (5.4) 416 (14.2)
254 (9.1) <0.001
<0.001 405(11.1)
314 (14.0) 570(17.5)
482 (19.6) <0.001
<0.001 220(3.8)
107 (7.5) 319 (10.9)
131 (4.7) <0.001
0.098
50–67 351 (11.1) 735 (22.6) <0.001 488 (15.6) 754 (23.4) <0.001 352 (11.2) 706 (21.7) <0.001
38–49 232 (7.9) 416 (14.2) <0.001 405 (14.0) 570 (19.6) <0.001 220 (7.5) 319 (10.9) <0.001
>67 221 (12.0) 692 (28.6) <0.001 308 (17.2) 686 (29.2) <0.001 325 (17.7) 908 (37.5) <0.001
50–67 351 (11.1) 735 (22.6) <0.001 488 (15.6) 754 (23.4) <0.001 352 (11.2) 706 (21.7) <0.001
Nationality a,b,c
>67 221 (12.0) 692 (28.6) <0.001 308 (17.2) 686 (29.2) <0.001 325 (17.7) 908 (37.5) <0.001
Spanish 911 (9.6) 1932 (19.7) <0.001 1392 (14.9) 2188 (22.6) <0.001 948 (10.0) 1925 (19.6) <0.001
Other 47 (3.6) 165 (10.6) <0.001 123(9.2) 304 (19.8) <0.001 56 (4.3) 139 (8.9) <0.001
Marital status a,b,c

Married 530 (7.6) 1117 (16.9) <0.001 900 (13.1) 1352 (20.6) <0.001 652 (9.4) 1127 (17.0) <0.001
Others 428 (11.2) 980 (20.6) <0.001 615 (16.3) 1140 (24.5) <0.001 352 (9.2) 937 (19.7) <0.001
Education level a,b,c

Primary 346 (13.9) 877 (28.9) <0.001 446 (18.3) 862 (29.1) <0.001 378 (15.2) 963 (31.7) <0.001
Secondary 487 (7.9) 913 (16.1) <0.001 832 (13.5) 1177 (20.9) <0.001 483 (7.8) 798 (14.1) <0.001
University 95 (4.9) 216(8.9) <0.001 208 (10.7) 357 (14.8) <0.001 118 (6.1) 188(7.8) 0.032
Int. J. Environ. Res. Public Health 2021, 18, 6350 5 of 15

Table 1. Cont.

Mental Disorders Psychological Distress Psychotropic Drug Consumption

Men Women Men Women Men Women
Variables p Value p Value p Value
n (%) n (%) n (%) n (%) n (%) n (%)
Social Class a,b,c
Upper 117 (5.7) 238 (11.4) <0.001 227 (11.2) 300 (14.4) <0.001 145 (7.1) 230 (11.0) <0.001
Middle 313 (8.5) 622 (17.5) <0.001 494 (13.6) 735 (20.9) <0.001 336 (9.2) 635 (17.8) <0.001
Low 516 (10.5) 1157 (21.3) <0.001 782 (16.1) 1382 (25.9) <0.001 513 (10.4) 1112 (20.5) <0.001
a Significant association for mental disorders in the total population. b
Significant association for psychologic distress in the total population. c
Significant association for psychotropic drug consumption in the total population. p-Values represent comparison between the male and
female population.

The highest prevalence of mental health disorders, psychiatric distress and psy-
chotropic drug consumption was found in both genders for the categories of older than
67 years, not married, with primary studies and low social class.
Being a woman was significantly associated with a higher prevalence of suffering from
mental health disorders, experiencing psychological distress and consuming psychiatric
drugs than being a man, according to all categories of the sociodemographic variables
included in the present study, with an exception made for the 18–37-year-old subgroup
which did not reach significant differences for psychotropic drug consumption (p = 0.098).

3.3. Prevalence of Mental Health Disorders, Psychiatric Distress and Psychotropic Drug
Consumption According to Health Status. Comparison between Men and Women
Table 2 shows the distribution of mental health disorders, psychiatric distress and
psychotropic drug consumption prevalence according to different health status variables,
including self-rated health by gender. According to the chronic conditions analyzed, the
highest prevalence of mental disorders was found in women who suffered from concomi-
tant stroke (43.3%), heart diseases (38.9%) and malignant tumors (38.1%). Meanwhile, the
highest prevalence of psychologic distress and psychotropic drug consumption was found
among women who suffered from mental disorders (53.6% and 63.6%, respectively), stroke
(45.3% and 46.2%, respectively) and heart diseases (42.6% and 41.1%, respectively).
Being a woman was significantly associated with a higher prevalence of suffering
from mental health disorders, experiencing psychiatric distress and consuming psychiatric
drugs according to all categories of health status variables included in the present study.
The only exception was the value of mental disorder prevalence, which did not reach
statistical significance when a comparison was carried out among genders (p = 0.070).

3.4. Prevalence of Mental Health Disorders, Psychiatric Distress and Psychotropic Drug
Consumption According to Use of Healthcare Services and Lifestyle-Related Variables. Comparison
between Men and Women
All variables related to the use of healthcare services and lifestyle analyzed in the
present work were significantly associated with mental health disorders, psychiatric dis-
tress and psychotropic drug consumption. As expected, it was found that women also
showed a significantly higher risk of developing mental health disorders, experiencing psy-
chological distress and consuming psychotropic medication compared to men according to
lifestyle variables. In terms of visits to a psychologist, no significant differences were found
in the prevalence of mental disorders, psychological distress or psychotropic medication
consumption according to gender (Table 3).
Int. J. Environ. Res. Public Health 2021, 18, 6350 6 of 15

Table 2. Mental disorders, psychologic distress and psychiatric drug consumption according to health status variables.
Results from the Spanish National Health Interview Survey 2017.

Mental Disorders Psychological Distress Psychotropic Drug Consumption

Men Women Men Women Men Women
Variables p Value p Value p Value
n (%) n (%) n (%) n (%) n (%) n (%)
Self-rated health a,b,c
614 854 564
Very good, good 288 (3.6) (8.2) <0.001 602 (7.6) (11.5) <0.001 276 (3.5) (7.6) <0.001

Fair, poor, very poor 670 (23.9) 1483 (37.8) <0.001 913 (33.3) 1637 (42.8) <0.001 728 (25.9) 1500 (38.2) <0.001
a,b,c 798 821 927
Hypertension 335 (13.1) <0.001 484 (19.2) <0.001 405 (15.9) <0.001
(29.9) (31.4) (34.8)
326 346 344
Heart diseases a,b,c 159 (15.9) (38.9)
<0.001 233 (23.8) (42.6)
<0.001 216 (21.6) (41.1)
<0.001

a,b,c 261 (19.0) 1010 (34.7) <0.001 356 (26.4) 1016 (35.6) <0.001 309 (22.5) 1142 (39.2) <0.001
Arthrosis
a,b,c 219 243 193
Permanent injuries 159 (18.2) <0.001 238 (27.8) <0.001 147 (16.8) <0.001
(37.4) (42.5) (32.9)
74 72 79
Stroke a,b,c 63 (27.9) (43.3)
<0.001 74 (35.1) (45.3)
0.040 81 (35.8) (46.2)
0.040

300 327 348

Diabetes mellitus a,b 145 (14.7) (33.7)
<0.001 219 (22.6) (37.8)
<0.001 180 (18.3) (39.0)
0.040

228 217 226

Malignant Tumors a,b,c 68 (17.4) (38.1)
<.001 112 (29.5) (37.5)
0.010 87 (22.3) (37.7)
<0.001

308 358 309

Respiratory diseases a,b,c 156 (16.7) (29.1)
<0.001 239 (26.0) (34.5)
<0.001 166 (12.7) (29.2)
<0.001

Chronic pain a,b,c 466 (18.1) 1413 (31.1) <0.001 665 (26.0) 1521 (33.9) <0.001 508 (19.7) 1375 (30.2) <0.001
b,c 958 (100) 2097 (100) NA 505 (55.3) 1081 (53.6) <0.001 578 (60.3) 1334 (63.6) 0.070
Mental disorders
Psychological distress a,c 505 (33.3) 1081 (43.4) <0.001 1515 (100) 2492 (100) NA 476 (31.4) 1028 (41.3) <0.001
a Significant association for mental disorders in the total population. b Significant association for psychologic distress in the total population. c
Significant association for psychotropic drug consumption in the total population. p-Values represent comparison between the male and
female population.

Table 3. Mental disorders, psychologic distress and psychiatric drug consumption according to use of healthcare services
and lifestyle-related variables. Results from the Spanish National Health Interview Survey 2017.

Psychotropic Drug
Mental Disorders Psychological Distress
Consumption
Men Women Men Women Men Women
Variables p Value p Value p Value
n (%) n (%) n (%) n (%) n (%) n (%)
Emergency 381 1147
956 (26.2) <0.001 650 (22.3) <0.001 455 (15.3) 981 (26.9) <0.001
services a,b,c (12.8) (32.1)
Hospital
137 (15.8) 289 (31.2) <0.001 260 (31.1) 366 (40.6) <0.001 197 (22.8) 346 (37.2) <0.001
admission a,b,c
Visit to physiother-
168 (10.0) 450 (21.2) <0.001 296 (17.7) 518 (24.6) <0.001 210 (12.4) 405 (19.1) <0.001
apist a,b,c
Visit to
301 (70.3) 507 (69.5) 0.750 238 (58.0) 404 (57.0) 0.720 273 (63.9) 443 (60.6) 0.260
psychologist a,b,c
Psychotropic drug 1334 1028 1004
578 (57.7) <0.001 476 (49.1) 0.210 2064 (100) NA
use a,b (64.7) (51.6) (100)
Obesity a,b,c 208 (10.9) 508 (28.0) <0.001 312 (16.5) 515 (28.9) <0.001 208 (32.2) 475 (53.8) <0.001
Alcohol 581 1065 1195
937 (14.6) <0.001 <0.001 618 (7.4) 872 (13.6) <0.001
consumption a,b,c (7.0) (12.8) (18.7)
Smoking habit a,b,c 344 (11.0) 480 (19.8) <0.001 513 (16.6) 559 (23.1) <0.001 300 (9.6) 386 (15.9) <0.001
Physical 511 1348
993 (15.1) <0.001 744 (20.5) <0.001 549 (7.8) 923 (14.0) <0.001
inactivity a,b,c (7.2) (28.7)
a Significant association for mental disorders in the total population. b Significant association for psychologic distress in the total population.
c Significant association for psychotropic drug consumption in the total population. p-Values represent comparison between the male and
female population.
Int. J. Environ. Res. Public Health 2021, 18, 6350 7 of 15

3.5. Variables Associated to Mental Health Disorders, Psychiatric Distress and Psychotropic Drug
Consumption after Multivariable Analysis
Table 4 shows the multivariable logistic regression adjusted ORs, identifying the
potential predictors for mental health disorders, psychiatric distress and psychotropic drug
consumption in the total study population.

Table 4. Variables independently and significantly associated with mental disorders, psychologic distress and psychiatric
drug consumption. Results from the Spanish National Health Interview Survey 2017.

Mental Disorders Psychological Distress Psychotropic Drug

Consumption
Variables Categories
OR OR OR
(CI 95%) p Value (CI 95%) p Value (CI 95%) p Value

Male 1 1 1
Gender 1.74 1.26 1.29
Female (1.54–1.96) <0.001 (1.15–1.37) <0.001 (1.15–1.45) <0.001

18–37 1 1 1

38–49 1.25 0.013 0.97 0.670 2.31 <0.001

(1.05–1.50) (0.86–1.10) (1.87–2.85)
Age (years) 1.41 0.78 3.61
50–67 (1.17–1.70) <0.001 (0.68–0.89) <0.001 (2.92–4.46) <0.001

>67 0.87 0.247 0.57 <0.001 6.13 <0.001

(0.69–1.10) (0.48–0.68) (4.79–7.83)
Spanish 1 1 1
Nationality 0.67 0.96 0.77
Other (0.55–0.82) <0.001 (0.84–1.09) 0.514 (0.62–0.95) 0.013

Married 1 1 1
Marital status 1.40 1.25 1.06
Other (1.25–1.58) <0.001 (1.14–1.36) <0.001 (0.94–1.19) 0.325

University 1 1 1
1.29 <0.001 0.88 0.126 1.24 0.051
Secondary (1.07–1.56) (0.75–1.04) (0.99–1.53)
Level of education
Primary 1.60 0.007 0.93 0.273 1.23 0.029
(1.31–2.02) (0.82–1.06) (1.02–1.48)
Upper 1 1 1
1.01 0.882 1.12 0.139 1.03 0.749
Middle (0.84–1.22) (0.97–1.27) (0.86–1.23)
Social class
1.10 1.21 0.93
Low (0.91–1.33) 0.331 (1.06–1.39) 0.006 (0.77–1.12) 0.429

Good 1 1 1
Self-rated health
Poor 2.17 <0.001 2.92 <0.001 1.87 <0.001
(1.91–1.33) (2.64–3.22) (1.64–2.12)

Emergency services Yes 0.95 0.399 1.31 <0.001 1.46 <0.001

(0.84–1.07) (1.20–1.44) (1.30–1.65)

Yes 0.64 <0.001 1.26 0.001 1.29 0.003

Hospital admission (0.53–0.77) (1.10–1.45) (1.09–1.52)

Yes 0.91 0.219 0.98 0.707 1.08 0.294

Physiotherapist visit (0.79–1.05) (0.88–1.09) (0.94–1.24)

Yes 7.50 <0.001 1.98 <0.001 5.10 <0.001

Psychologist visit (6.21–9.06) (1.68–2.32) (4.21–6.17)

Hypertension Yes 1.02 0.826 1.05 0.402 1.24 0.001

(0.88–1.16) (0.94–1.17) (1.09–1.41)

Yes 1.13 0.185 1.22 0.007 1.07 0.411

Heart diseases (0.94–1.35) (1.05–1.40) (0.91–1.26)

Yes 1.09 0.252 1.11 0.073 1.39 0.000

Arthrosis (0.94–1.26) (0.99–1.25) (1.22–1.59)

Permanent injuries Yes 1.33 0.003 1.63 <0.001 0.87 0.166

(1.10–1.61) (1.42–1.88) (0.72–1.06)

Yes 1.49 0.021 1.45 0.007 1.39 0.036

Stroke (1.06–2.09) (1.11–1.91) (1.02–1.89)

Yes 0.98 0.873 1.15 0.056 0.95 0.533

Diabetes mellitus (0.82–1.18) (1.00–1.33) (0.80–1.12)
Int. J. Environ. Res. Public Health 2021, 18, 6350 8 of 15

Table 4. Cont.

Mental Disorders Psychological Distress Psychotropic Drug

Consumption
Variables Categories
OR OR OR
(CI 95%) p Value (CI 95%) p Value (CI 95%) p Value

Yes 1.28 0.025 1.31 0.002 1.04 0.690

Malignant tumors (1.03–1.58) (1.10–1.56) (0.85–1.28)

Yes 1.03 0.732 1.26 <0.001 1.05 0.578

Respiratory diseases (0.87–1.22) (1.10–1.43) (0.90–1.24)

Yes 1.72 <0.001 1.43 <0.001 1.42 <0.001

Chronic pain (1.52–1.95) (1.30–1.57) (1.26–1.60)

Yes 1.23 0.004 0.93 0.176 0.88 0.062

Obesity (1.07–1.41) (0.83–1.03 (0.76–1.00)

Yes 0.85 0.007 0.93 0.126 0.87 0.017

Alcohol consumption (0.75–0.95) (0.85–1.02) (0.77–0.97)

Yes 1.47 <0.001 1.13 0.017 1.17 0.021

Smoking habit (1.29–1.68) (1.02–1.24) (1.02–1.34)

Yes 0.99 0.959 0.68 <0.001 0.93 0.196

Physical activity (0.89–1.12) (0.62–0.73) (0.83–1.04)

Yes 10.35 <0.001 1.77 <0.001 -

Psychotropic drugs (9.15–11.69) (1.57–2.00)

Yes 2.80 <0.001 - 1.81 <0.001

Psychological distress (2.48–3.15) (1.59–2.04)

Yes - 2.72 <0.001 10.46 <0.001

Mental disorders (2.41–3.06) (9.26–11.82)
Categories “yes” were compared to “no” (reference categories, not shown) for each variable. CI: confidence interval.

After adjusting for possible confounders, women had a 1.74 (95% CI 1.54–1.96) fold
probability of reporting mental disorders, 1.26 (95% CI 1.15–1.37) fold of reporting psycho-
logical distress and 1.26 (95% CI 1.15–1.45) fold of reporting psychotropic drug consumption
compared to men (all p < 0.001).
Results revealed that in addition to being a woman, being aged 37–67 years; not being
married; having a medium–low education level (secondary and primary studies); having
poor self-rated health; visiting a psychologist; suffering from a chronic disease, such as
stroke, malignant tumors, chronic pain and psychologic distress, or having permanent
injuries caused by an accident; and having unhealthy lifestyles, including obesity, psy-
chotropic drug consumption or a smoking habit were identified as risk factors for reporting
mental disorders. On the other hand, being an immigrant and consuming alcohol were
found to be protective factors against mental disorders among residents in Spain.
Our results also showed that positive predictors for psychological distress included not
being married; coming from a low social class; having poor self-rated health; using emer-
gency and psychological services or being admitted to hospital; suffering from a chronic
disease, such as heart disease, stroke, diabetes mellitus, malignant tumors, respiratory
diseases and chronic pain, or having permanent injuries caused by an accident; suffering
from mental disorders; and having an unhealthy lifestyle, including a smoking habit and
psychotropic drug consumption. By contrast, being older than 50 years and engaging in
physical activity were described as negative predictors for psychological distress.
As Table 4 shows, positive predictors for psychotropic drug consumption were an age
older than 37 years; not being married; low educational levels (primary and secondary
studies); poor self-rated health; use of emergency and psychologic services and hospital
admission; several chronic diseases, including hypertension, arthrosis, chronic pain, psy-
chologic distress and mental disorders; and a smoking habit. Being an immigrant and
consuming alcohol were found to be negative predictors for psychotropic drug consumption.
Table S2 shows the specific variables associated with the three study variables among
men and women after multivariable analysis. Interestingly, there are several independent
variables that have a different effect on mental health status and psychotropic drug con-
sumption according to gender. Chronic diseases such as heart disease, stroke, permanent
injuries and obesity were only identified as positive predictors for mental disorder among
Int. J. Environ. Res. Public Health 2021, 18, 6350 9 of 15

women. In addition, the variables of low social class and several chronic diseases (heart
disease, arthrosis, malignant tumors and respiratory diseases) also showed differential
effects on psychological distress risk according to gender. On the other hand, a nationality
other than Spanish, primary level of education, several chronic diseases and alcohol con-
sumption also seem to exert a different effect on psychotropic drug consumption between
men and women.

4. Discussion
In the present study, the prevalence of mental disorder, psychologic stress and psy-
chotropic treatment according to different sociodemographic, health- related and lifestyle
variables was analyzed in a large and representative sample of the resident population in
Spain based on data from the SNHIS 2017. Results emphasized the increased prevalence of
mental disorders, psychological distress and psychotropic medication in women compared
to men. In addition, sociodemographic, health status and lifestyle variables were identified
as potential predictors for mental health status and psychotropic treatment.
According to the Institute for Health Metrics and Evaluation (IHME 2018), 17.3%
of people across EU countries had a mental health problem in 2016, with an estimated
prevalence of 18.3% for Spain [8]. This estimation is similar to results obtained in the present
study, where percentages of mental disorder and psychological distress prevalence reached
up to 13.8% and 18.3%, respectively. What is remarkable is that this prevalence is lower than
the values of 15.4% for mental disorder and 22.1% for psychologic distress obtained in Spain
using the previous SNHIS 2011–2012 [27]. At the European level, the highest prevalence of
mental health disorders is located in Finland, the Netherlands, France and Ireland, with
rates of 18.5% or more, while Romania, Bulgaria and Poland showed the lowest prevalence,
with rates of less than 15% of the population. Therefore, according to SNHIS2017 data,
Spain would be ranked among the European countries with the lowest prevalence of mental
disorders [8]. These marked differences among European countries may be due to the
fact that people living in countries with greater awareness and less stigma associated with
mental illness, as well as easier access to mental health services, may be diagnosed more
easily or may be more likely to self-report mental ill health. However, there are countries
where mental disorders are still strongly stigmatized, and it is thought that it is better
to simply avoid talking about mental illness [28]. Our results also showed a decreased
prevalence of prescription of psychotropic drugs compared to those reported in previous
studies using the SNHIS 2011–2012 (SNHIS2017: 13.9% vs. SNHIS2011-2012: 15.6%) [11].
This descending trend across time has also been observed in other studies conducted
in Spain with other methodological designs [29,30]. It contrasts results obtained from
several countries such as Norway, the USA or Canada, where an increased prescription of
psychotropic drugs was reported during the last decade [31–35]. The decreased prevalence
of prescription of psychotropic drugs observed in the present study may be explained,
at least in part, by the particularly adverse economic crisis that affected Spain starting in
2008 [36], which only began to recede in 2015 [37], just before data recruitment started for
the present study. In different countries, the adverse effects of economic recession on mental
health have been described, and how mental health status has improved after the economic
crisis receded [29,38–40]. Our results also revealed that crude and adjusted prevalence
of mental disorders, psychological distress and psychotropic medication consumption
were higher among women than among men. In accordance with our results, there is
a large body of scientific evidence supporting the occurrence of poorer mental status
health and increased psychotropic medication consumption among women compared to
men [7,27,30,41–43]. Possible explanations for these results may be related to differences
in emotional processing and coping skills, willingness to report diseases or structural
inequalities and even intrinsic biological factors such as hormone mechanisms [29]. In
addition, despite great changes in female gender roles in recent decades, traditional gender
roles that entail housework, childbearing, gender discrimination and gender-based violence
promote exposure to stressors that can lead to psychological distress among women [29].
Int. J. Environ. Res. Public Health 2021, 18, 6350 10 of 15

Age was also identified as a positive predictor for mental disorder; however, only the
age range of 37–67 years reached statistical significance. This finding is consistent with
previous studies based on epidemiological surveys [7], suggesting that common mental
disorders such as anxiety and depression have an early age of onset [44]. Age older than
50 years was also found to be a protector for psychologic distress. This observed pattern of
decreased prevalence of mental disorder and psychologic distress with increasing age seems
to be in accordance with the widely accepted socioemotional selectivity theory (SST) [45].
This theory concludes that older adults adopt a present-focused state of awareness, seeking
the achievement of emotionally meaningful goals through relatives and friends, which
increase the likelihood of experiencing positive emotions [45]. On the other hand, increased
age was strongly identified as a predictor for psychotropic drug consumption. It is widely
known that the prescription rate of psychotropic drugs increases with age, with mental
health problems associated with aging identified as the main factor behind the use of these
drugs [46,47]. However, our results suggest that mental health problems may not be the
only factor or even the decisive one for psychotropic drug consumption, and therefore, the
possibility of the presence of other predisposing factors must be considered. Regarding
this last point, in addition to the presence of mental health problems, factors such as
physiological alterations of sleep patterns, number of chronic disorders, limitations in
functional abilities and even characteristics of those prescribing the medicine have been
closely associated with the prescription of psychotropic drugs [48–50].
Additionally, in accordance with previous studies, not being married has been found to
be a positive predictor for mental disease and psychologic distress. A plausible explanation
for this may be that the married population may avoid feelings of loneliness and feel higher
levels of emotional and psychological wellbeing [51,52].
Being an immigrant was found to be a negative predictor for poor mental health and
psychotropic medication consumption. Different aspects closely related to immigration
such as lack of social or economic factors or cultural changes have been widely associ-
ated with an adverse impact on mental health [53]. However, different conditions may
modulate the relationship between immigration and high risk of developing mental al-
terations. A previous report performed in Spain concluded that immigrants who resided
in Spain for less than 10 years showed a better state of mental health than the Spanish
population [54]. Other works outside Spain have also reported that the mental health
of immigrants was found to be similar or better than that of the native population of
the destination country [55–57]. However, it is important to point out that data obtained
about a good mental health state among immigrants may be biased, since people with
poorer mental health would have lower possibilities to migrate. In this regard, different
works have shown that physical and mental wellbeing were factors driving the decision to
migrate [58,59].
The inverse relationship between mental health alterations and social class and edu-
cation levels are two of the most well established in the field of mental health epidemiol-
ogy [60,61]. However, our results did not reveal the abovementioned inverse relationship.
Uniquely, secondary and primary levels of education were identified as a predictor for men-
tal disorders, while education levels were found to predict neither psychological distress
nor psychotropic drug consumption. These controversial results may be due to the effect
of social class and educational level on mental health being modulated by other aspects
closely associated with the welfare state of a country. In this regard, it is important to note
that when the data for the present work were collected, Spain had Europe’s second highest
unemployment rate, the third highest percentage of underemployed part-time workers
who wished to work more (51%) and the second highest rate of youth unemployment
(43%) [62]. With these data, it would be plausible to think that stress due to unemployment
or temporary employment status would increase the risk of developing poor mental health,
independently of social class and education level. However, when the effect of social class
on psychological distress was analyzed according to gender, it was found that a low social
class was a predictor of psychological distress among women. This may be associated with
Int. J. Environ. Res. Public Health 2021, 18, 6350 11 of 15

the demanding responsibilities of housework and parenting of children among women

who belong to a low social class in Spain [63], which would provide additional stress in
comparison to men, independently of employment status.
Our results showed that the population with a negative perception of their health were
in higher risk of mental disorders, psychologic distress and psychotropic drug consumption,
agreeing with previous reports [11,19]. In addition, as was expected, psychologist consul-
tations were also associated with poor mental health status and psychotropic medication
consumption. Interestingly, our results also revealed that emergency and non-emergency
hospital admission increased psychologic distress risk and psychotropic drug consumption.
These findings may also be closely associated with the presence of chronic disorders. The
diagnosis of chronic disorders often requires numerous visits to the doctor and exposes
the patient to chronic stressors which may lead to psychological distress and, therefore,
the prescription of psychotropic drugs. Regarding this point, we have found that chronic
disorders such as malignant tumors, stroke, permanent injuries and pathologies with
chronic pain are all characterized by a high emotional charge for patients due to treatment
and psychosocial or labor stressors, and they were a positive predictor for poor mental
health and psychotropic medication consumption. This is consistent with findings from
previous works [11,64,65].
In line with other studies conducted in Spain and other countries, our analysis of
variables associated with lifestyle revealed that obesity was a predictor of mental disor-
ders [66–69]. Interestingly, our results also revealed that obesity was a predictor of mental
disorders only for women. A negative self-perceived body image is closely associated
with low levels of perceived social support, particularly in the female population [70,71].
Perceived social support plays a crucial role in enjoying a sense of general wellness and
even as a stress-buffering process [72,73]. In our population, engaging in physical exercise
was significantly associated with lower psychological distress. This protective effect of
physical activity has been previously described in the Spanish general population [23].
Regarding the consumption of addictive substances, smoking was a predictor of mental
disorders, psychologic distress and psychotropic drug consumption. There is strong evi-
dence for an association between smoking and the development and progression of mental
disorders and psychotropic drug consumption [11,74]. On the other hand, the negative
association between consumption of alcohol and both mental disorders and psychotropic
drug consumption found in our work may be because alcohol is used as an alternative
substance instead of psychotropic medicines for those who are suffering from anxiety
or depression, especially in the male population [75]. Accordingly, we found that the
protective effect of alcohol consumption on psychotropic drug consumption was limited to
the male population.
As expected, a positive association was found between the presence of mental disorder,
psychologic distress and psychotropic drug consumption. These variables are closely
related to each other. The positive directional association between distress and mental
disorder is widely accepted, indicating that any study claiming to focus on mental health
should incorporate measures of distress and mental disorders [76].
The main strength of this work was the use of a representative sample of the popula-
tion residing in Spain, which allowed quantifying the prevalence of poor mental health
status and psychotropic drug consumption as well as identifying predictors involved in
the processes mentioned above. However, there were also several limitations to this study.
The SNHIS is based on self-reported data, and therefore, it may be affected by nonresponse
bias, memory bias or the tendency of interviewees to give socially desirable responses.
Moreover, national health surveys rely on household sampling, but we do not have data
from institutionalized populations, nor from hospitals and prisons or marginalized groups
(e.g., the homeless population), who often have high rates of mental disorders and psy-
chotropic treatment [77]. These taken all together, it is possible that the prevalence of poor
mental health status and psychotropic drug consumption may be underestimated. Finally,
the use of a cross-sectional design means that causality cannot be inferred.
Int. J. Environ. Res. Public Health 2021, 18, 6350 12 of 15

5. Conclusions
In conclusion, our findings show a high prevalence of poor mental health status and
psychotropic drug consumption in Spain, emphasizing that gender differences exist, with
women being in higher risk of mental disorder, psychological distress and psychotropic
drug consumption. However, this prevalence seems to have decreased in comparison to
what was identified during analysis against the backdrop of a particularly hard economic
crisis in Spain. Different sociodemographic, health status and lifestyle factors appear
to be associated with a prevalence of mental health status and psychotropic medication
consumption. Programs targeted at preventing, monitoring and controlling these gender
differences in mental health problems should be implemented in primary care. Screening
for these conditions should be considered, particularly in Spanish women, younger adults
and individuals who are not married, have poor self-rated health, suffer from chronic
diseases or have a smoking habit.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/ijerph18126350/s1, Table S1: Definition of dependent and independent variables used in our
investigation according to the questions included in the Spanish National Health Interview Survey
2017 (SNHIS 2017). Table S2: Variables independently and significantly associated with mental
disorders, psychologic distress and psychiatric drug consumption according to gender. Results from
the Spanish National Health Survey 2017.
Author Contributions: Conceptualization, C.M.-M., R.J.-G. and J.J.Z.-L.; formal analysis, A.B., S.S.-R.
and D.C.-A.; methodology, A.L.-d.-A., Z.J., J.d.M.-D. and A.L.-F.; writing—original draft preparation,
C.M.-M., R.J.-G. and J.J.Z.-L.; writing—review and editing, A.B., S.S.-R., D.C.-A., A.L.-d.-A., Z.J.,
J.d.M.-D. and A.L.-F. All authors have read and agreed to the published version of the manuscript.
Funding: No funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: This database can be downloaded freely and without cost from
the website of the Ministry of Health, Social Services, and Equality (https://www.mscbs.gob.es/
estadEstudios/estadisticas/encuestaNacional/encuesta2017.htm, accessed on 20 May 2021). All rele-
vant data, however, are already presented within this paper.
Conflicts of Interest: The authors declare no conflict of interest.

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