Territorial inequalities in mental health in Catalonia (Spain): a spatial epidemiological analysis

Background

Anxiety and depression are public health concerns and are unequally distributed across populations. Less is known about how these inequalities vary across territories and the role of social determinants.

Methods

We conducted a cross-sectional study using data from the 2021–2024 Catalan Health Survey (ESCA), including individuals of working age (18–67 years) (N = 8,142; 50.6% women). Outcomes were physician-diagnosed anxiety and depression in the previous 12 months (yes/no). Bayesian spatial logistic regression models (INLA) were used to assess territorial variation across health sectors, adjusting for sex, age, labour market status, material deprivation, financial strain, social support, education, place of birth, chronic conditions, and survey year. Additional models restricted to employed individuals included occupational conditions: job insecurity, contract type, occupation, working schedule.

Results

After adjustment, anxiety showed a clear territorial pattern, with higher risk concentrated in central and coastal areas and lower risk in inland regions. This pattern remained stable across models. In contrast, depression showed weaker and less consistent spatial variation, with territorial differences attenuated after adjustment. Strong social inequalities were observed for both outcomes: women (OR 2.4 for anxiety; 2.7 for depression), financial strain (OR 1.6; 1.8), and poor social support (OR 1.7; 2.01). Among employed individuals, occupational conditions, particularly job insecurity, were associated with anxiety, while fewer associations were observed for depression.

Conclusions

Social determinants of health explain an important share of the territorial distribution of anxiety and depression, but do not fully account for observed spatial inequalities. The persistence of geographical patterns, particularly for anxiety, suggests the influence of additional contextual factors.

Key messages

• Anxiety shows persistent spatial inequalities after adjustment for social and health determinants, suggesting an additional role of contextual influences.

• Depression is largely explained by social and health determinants, with limited residual spatial variation across health sectors.